The diaphragm is a shallow rubber cap with a rim made of a fine, flexible spring (Figure 4.1). It fits snugly and comfortably across the upper vagina, covering the entire cervix, thus preventing sperm from getting into the uterus and fallopian tubes to fertilize an egg. It is used with a spermicidal (sperm-killing) jelly or gel.

The diaphragm is a popular method of birth control because it does not cause any hormonal or chemical changes in the body. It has almost no side effects and does not have to interrupt lovemaking. Few men are bothered by the presence of a diaphragm, if they even notice it. It can be used during menstruation.

When used consistently and carefully, a diaphragm plus spermicide offers quite good protection against pregnancy and those sexu-

FIGURE 4.1 Diaphragm

ally transmitted diseases caused by bacteria. The risk of pelvic inflammatory disease (PID) is reduced substantially by the use of a diaphragm. Whether it protects against AIDS and other virus-caused diseases has not yet been proved.

A diaphragm needs to be fitted by a doctor or other health care provider and generally can be used for several years or longer.

The diaphragm is a particularly good method if you do not have sex frequently or if you know in advance when you will have intercourse. If you own a diaphragm but are now on the Pill, the diaphragm can provide good emergency protection if you run out of pills or are vulnerable to pregnancy because you forgot to take two or more pills. Some couples like the idea of using a contraceptive only when they believe that the woman is fertile, and they use a diaphragm, cervical cap, or condom during that time.

To be most effective, the diaphragm is used with a spermicide. It must be inserted before intercourse and must remain in place for 6 hours afterward. It should be kept handy even when you do not expect to have sex. You also need to keep a supply of spermicide on hand.

It has a few disadvantages. If you often try different positions when having sex, you may find that the diaphragm can be dislodged when the woman is on top. This does not happen often or to everyone, but it is possible. It may depend on the woman's anatomy or the fit of the device.

During oral sex, some spermicides can leave an unpleasant taste, although this can be eliminated by wiping off your genital area after you insert the diaphragm. Both flavored and unflavored spermicidal products are available.

A spermicide is recommended because the diaphragm itself may not be completely effective in stopping sperm from entering the cervix. During intercourse, the vagina can flex and change in shape. As a result, a diaphragm cannot provide a perfect seal, and some sperm may slip past it. To protect against this possibility, a spermicidal jelly or cream is used with the diaphragm each time. One of the diaphragm's functions is to hold spermicide close to the cervical

opening to destroy any sperm that get past the rim. Approximately two teaspoons of a spermicide are put in the cup of the diaphragm before it is inserted. (For more information on spermicides, see Chapter 6.)

Like condoms and cervical caps, the diaphragm's effectiveness depends directly on how carefully and consistently it is used. Rates of failure vary widely, ranging from 5 to 21 percent during the first 12 months of use. Women who do not use the diaphragm every single time they have sex have the highest failure rate. Women who use it carefully every time they have sex experience the lowest rate of failure. Leaving the diaphragm at home is one of the most common reasons for failure.

Age and frequency of intercourse also affect the chance of failure. Diaphragm users who are under age 25 or who have sex frequently run a greater risk of becoming pregnant. Men and women in their teens and twenties are usually extremely fertile, which increases their risk of pregnancy. And, when intercourse is frequent, there are more chances for contraceptive failure, unless the couple is very disciplined about using this or any barrier method.

To prevent pregnancy and disease, it is necessary to use the diaphragm every time you have sex, even during menstruation and the so-called ''safe" days shortly before or after menstruation. For greatest protection, a condom can be used in addition during the woman's most fertile days. (For information on determining your fertile and nonfertile days, see Chapter 14.)

As a rule, the diaphragm produces no serious, negative effects on the body, nor can it be lost in the vagina or in the upper reproductive tract.

A diaphragm used with a spermicide is an effective barrier against the organisms that cause such STDs as gonorrhea, trichomoniasis, and chlamydia. In addition, cancer of the cervix has been found to be much less common in women who consistently used a diaphragm during intercourse for at least 5 years.

Some women who wear diaphragms have a slightly increased risk of repeated urinary tract infections. The pressure of the rim on the urethra and bladder may be a factor in this. A diaphragm in a smaller size or with a different type of rim may exert less pressure and eliminate this possibility. As a precaution against infection, the diaphragm should be washed thoroughly with soap and water after each use, and the user should wash her hands before taking it from the case.

Symptoms of this rare syndrome include fever, diarrhea, vomiting, muscle aches, and a sunburn-like rash, particularly on the palms of your hands and the soles of your feet. If these should occur, call your doctor. Although toxic shock is unusual, it is so serious the possibility should not be overlooked.

In some instances, a diaphragm user or her partner is allergic to the latex or the spermicide. Women experience this problem more often than men, developing an irritation in the vagina. The cause may be a sensitivity to the perfumes used in certain brands of spermicides or to nonoxynol-9, the active ingredient. Using an unscented spermicide, or one that contains less nonoxynol-9, may solve the problem. To discover if the allergy is from the spermicide, insert some by itself into the vagina without the diaphragm. Either have

no sex during this time or do this during the nonfertile days of your cycle. If you can do this for several days without irritation, the spermicide is probably not the cause.

Instead of an allergy, sometimes vaginal soreness is just the result of irritation from the spermicide. Talk to your health care provider about this problem and about using another, nonirritating form of contraception. Condoms may provide a solution, and the cervical cap is another choice. Since it requires very little spermicide, the cap can sometimes be a good method for women who tend to be irritated by spermicides (see Chapter 5).

If the spermicide is not the source of the irritation, latex is the likely suspect. Since all diaphragms today are made of latex, if you want to continue with a barrier method, the only nonlatex choices are the new polyurethane or Tactylon male condoms (Chapter 2) or the female condom (Chapter 3).

Diaphragms are available from women's health centers and Planned Parenthood clinics, from physicians, particularly family practitioners and gynecologists, and from nurse-midwives, nurse-practitioners, and other health professionals specializing in family planning. Spermicides are also available from these sources or from the feminine hygiene or family planning sections in drugstores.

Diaphragms are available in sizes measured in millimeters, ranging from 50 to 95 millimeters (about 2 to 4 inches) in diameter. The size you need depends on the size of your upper vagina, which is related to your body size and weight, as well as whether you experienced a vaginal childbirth. Diaphragms are available with different types of rims that make it possible to fit many different bodies.

The diaphragm with a flat spring rim exerts a very gentle pressure. It is often the best choice for the woman whose vaginal muscles are very firm because she has not yet had a baby. A coil spring rim is stronger and is designed for the vagina with a more relaxed muscle

wall. A diaphragm with an arcing spring rim bends in only two places, which some women find easier to handle.

Both the arcing spring and coil spring types are available with an extra "wide seal" inner rim of soft latex. This is intended to create a better seal with the vaginal wall and to be more effective in holding the spermicide around the cervix.

Because the diaphragm must fit very well, it is necessary to have an internal pelvic examination by a physician or other health care provider. The examination rules out any problem that would prevent you from using a diaphragm successfully, such as an abnormality of the vagina, cervix, or uterus. This is also a good time to ask to be examined for infections of the lower reproductive tract. Many infections have no symptoms and without a lab test they could remain undiscovered. They should be treated before they cause complications.

If you are under age 18 and wonder if the clinic or physician will tell your parents about your visit, you may find it helpful to ask some of the privacy questions listed on page 234 in Chapter 18.

During the exam, the practitioner will assess which type and size of diaphragm will suit your body best. This usually is done with fitting rings or sample diaphragms, and several may have to be tried to find the size that is comfortable and secure in the vagina. The ideal is the largest model that is snug without discomfort. A diaphragm is a good fit if it touches the walls of the vagina with just enough room to insert a fingertip beneath the pubic bone.

If you are not at ease with the idea of inserting and removing a diaphragm by hand, some types can be used with a plastic inserter. Discuss this possibility with your practitioner.

Part of the fitting procedure must include a lesson on how to insert and remove the diaphragm. You should be given plenty of opportunity to practice while you are still in the examining room. If the rim is too stiff to be squeezed together by one hand, a model with a less firm spring may be preferable. Although more practice with

the diaphragm will make it easier to use, you should feel fairly confident about inserting it before you leave the clinic.

If you wish, it usually is possible to take the diaphragm home to practice inserting it and then, while wearing it, go back to your practitioner to make sure it is in the right place. This is not possible if you are simply given a prescription for buying the diaphragm at a drugstore.

You want to be able to put it in and take it out correctly and easily before you actually use the diaphragm. If it is a good fit, you should not be able to feel it. It may be too large if you feel the need to urinate shortly after you put it in or if you have a sense of pressure on your abdomen. When abdominal pain or cramping or vaginal pressure accompany the presence of the diaphragm, its position and size should be checked. Do not accept one that causes you any discomfort when it is correctly placed.

• Before putting in the diaphragm, wash your hands. If you are not familiar with the anatomy of your vagina and cervix, you will find it easier to use this method if you know where your cervix and pubic bone are (see Chapter 1) and what they feel like. There is no need to be embarrassed—after all, this is an important part of your body and you should know about it.
• Fill the diaphragm almost two-thirds full of a spermicide (a couple of inches or about 2 or 3 teaspoons). How much you need depends on its size: a larger one will require more spermicide. Spread it around and up on the inside of the rim. For extra protection, some women smear a bit of spermicide on the outside of the diaphragm or put a dab on one spot of the outer rim, which is less messy. Avoid making the outside of the rim too slippery—you may find the diaphragm flying out of your hand!
• You can insert the diaphragm while sitting on the toilet, or lying down with your legs bent, or in a squatting position—whatever works for you (Figure 4.2). If you sit on the toilet, take care that the rim of the diaphragm is not slippery from spermicide because it may slip from your hands.

• If you ever drop your diaphragm, wash it well with soap and water, add spermicide, and start over.
• With the open side of the cup facing upward, firmly squeeze the sides of the rim together between your thumb and fingers to fold it for insertion. If the spermicide has made the rim too slippery to grasp, wipe it from the outer edge only, not from the inside. A little spermicide in one spot on the leading edge, however, does help it slide more easily into the vagina.
• While you hold the folded diaphragm in one hand, spread apart the lips of the vagina with the other hand and then ease the diaphragm up into the vaginal canal as far back as it will go—about two or three inches. The leading edge of the rim should slip under and behind the cervix and touch the vaginal wall. Then gently but firmly push the other edge up behind the pubic bone. When it is in the correct position, the diaphragm should cover the cervix, feel comfortable, and stay in place.
• Use your longest finger to make sure the rim of the diaphragm closest to the vaginal opening is tucked up behind the pubic bone and that the cervix is covered by the soft rubber dome. Your cervix is at the upper end of your vagina—it feels like the tip of your nose and you should be able to feel it through the latex. Touching it through the diaphragm also makes sure the spermicide is in contact with the cervical opening, protecting it from sperm.
• If you are aware of your diaphragm when you are wearing it, it is probably not correctly placed. Take it out and try again. Try sitting differently when you insert it. Also make more of an effort to keep the leading edge of the diaphragm low so it goes under the cervix. Remember that using any barrier method is awkward at first and it takes a little practice before the diaphragm becomes easy to insert.

Spermicides lose their effectiveness in the body as time passes. If you inserted the diaphragm more than two hours before actually having sex, squeeze another application directly into your vagina.

To use the plastic applicator that comes with the spermicide, remove the cap from the tube and attach the applicator in its place. Squeeze the tube so the jelly, gel, or cream pushes into the applicator and fills it. Disconnect the applicator and insert it well into your vagina, just as you would a tampon, and then gently push the plunger in as far as it will go. When you remove the applicator, do not tug on the plunger because that might pull some of the cream back into it. Contraceptive foams, available in most drugstores, can be used with diaphragms instead of a cream or gel (for more information on spermicide products, see Chapter 6). You can apply the spermicide in the bathroom or while still in bed. It takes only a moment.

As we noted in the chapter on condoms (Chapter 2), when you use a latex device, it is vital not to use petroleum jelly or any other oil-based ointment or cream instead of a spermicide. For one thing, these products do not kill sperm. For another, any product with oil in it weakens latex and causes it to develop tiny holes that allow sperm, viruses, and bacteria to pass through. If you want to use a lubricant during intercourse, use your spermicide or a water-based vaginal lubricant such as K-Y Jelly, Ortho-Gynol, or Koromex Gel. When you buy a lubricant, read the label carefully to make sure it is safe to use with latex.

After sex is over, leave the diaphragm in place for at least 6 hours. It takes that long for the spermicide to kill all the sperm. Although in some cases the diaphragm can be dislodged if the vagina flexes a great deal during intercourse, you can safely take a bath, shower, swim, bicycle, and perform almost any kind of physical activity without it moving out of place. You also can have a bowel movement without dislodging it. Do not douche while wearing a diaphragm. Douching washes away protective spermicides and can force sperm up the cervix.

You can leave the diaphragm in place for longer than 8 hours, and many women prefer to do so. In fact, it is usually more convenient to wait until morning to remove it. But do not leave it in for more than 24 hours at a stretch. Leaving barriers in place for extended periods of time may be associated with increased risk of toxic shock syndrome.

Before having more sex, add an applicator of spermicide. If 8 or more hours have passed, and you expect to have intercourse again, you can remove and wash the diaphragm if you wish, add more spermicide, and reinsert it. Or you can just leave the diaphragm in place and add more spermicide.

Before removing the diaphragm, again, wash your hands. Then find a comfortable position. Hook a finger under the part of the diaphragm that rests behind the pubic bone or at any other point

toward the front of the vagina. Firmly pull forward and down. If it is a good fit, it may take a bit of effort to dislodge the diaphragm. Be careful not to poke a fingernail through it. Because a certain amount of sperm and contraceptive cream will come out of the vagina with the diaphragm, many women remove their diaphragms while sitting on the toilet. The use of a minipad or tampon will protect you against any leakage afterward.

Simple care extends a diaphragm's life and effectiveness. After using it, wash it with soap and warm water, rinse, and pat it dry with a clean towel. (A diaphragm should not be put away while still wet.) Do not use antiseptics or strong cleansing solutions on a diaphragm, because they weaken the latex. To protect it further, before returning it to its case, dust the diaphragm with cornstarch—not talcum or any other perfumed powders; the perfumes can damage it. Store your diaphragm in its case and do not expose it to sunlight or extreme heat.

Examine your diaphragm every few weeks for holes, especially around the rim. Even the tiniest pinhole can admit hundreds of sperm. To make a check, hold it up to the light and look at it carefully. Or fill it with water to see if it leaks. The latex will gradually grow darker with time; this is all right, it does not affect its function. Replace the diaphragm when the rubber shows signs of deterioration, such as cracks or brittleness.

Your diaphragm and its fit should be checked every 18 months or so. This can be done when you have your regular pelvic exam and Pap smear. The fit should also be checked in the following circumstances:

• if you have lost or gained more than 20 pounds;
• if you have had a child, a miscarriage, an abortion, or any type of surgery involving your reproductive organs;

• anytime you experience discomfort, pain, or recurring bladder infections after using the diaphragm; or
• anytime you suspect your diaphragm is not fitting properly or that you might not be inserting it correctly.

The medical examination and a diaphragm fitting can cost from $75 to $150 or more, depending on where you live and who does it. Women's health centers, state or city family planning clinics, and Planned Parenthood clinics usually offer the lowest costs. The most expensive source may be your gynecologist. However, if you have been having regular pelvic examinations, your gynecologist, internist, family practitioner, or adolescent medicine specialist may do just the fitting procedure for less than the cost of an exam. The cost of the diaphragm may be included.

Prices of spermicidal gels, jellies, and creams begin at $8 and the tubes vary in the number of ounces they hold. An ounce of spermicide is equal to 6 teaspoons or 2 to 3 applications. A 3.8 ounce tube contains about 10 applications. Read the label to be sure the contents actually are a spermicidal—are intended to kill sperm. Some vaginal lubricants that do not contain nonoxynol-9 (the active sperm-killing ingredient) are sold in similar packages, although they usually are much cheaper. Contraceptive foams and gels often are available at reduced cost from Planned Parenthood and other family planning clinics.

If you need to replace your diaphragm, it is usually not necessary to have another pelvic examination. If you make a note of the size of your diaphragm, the health care practitioner who provided it can telephone a prescription for a new one to your pharmacy. The size is usually printed on the rim. It should also be noted in your medical records.