What is a diaphragm?
The diaphragm, which was developed in the 19th century, is one of the oldest methods of preventing pregnancy. It is a latex dome which is inserted into a woman’s vagina prior to sexual intercourse. Silicon diaphragms are also available for women who are allergic to latex.
The dome is placed so that it covers the woman’s cervix, and thus creates a barrier which prevents sperm from entering the uterus. A flexible spring, found in the rim of the diaphragm, prevents the dome from moving out of place during intercourse.
The device must be fitted by a health professional, to ensure the correct size diaphragm is selected, however once a diaphragm has been fitted, a woman can easily insert and remove the diaphragm before and after sexual intercourse. Diaphragms are typically used in conjunction with spermicides to increase their effectiveness.
The diaphragm prevents pregnancy by blocking the cervical opening (the entrance to the uterus). It therefore prevents sperm from entering the uterus. If a woman is fertile, (if she has a viable egg in her uterus) sperm must enter the uterus to fertilise the egg. The egg cannot be fertilised once it has been expelled into the vagina. Thus, by preventing sperm from entering the uterus, the diaphragm also prevents sperm coming into contact with and fertilising an egg.
Most women can safely use a diaphragm. However, some women may need to delay diaphragm use, and use a different method until they can safely use a diaphragm. These women include:
- Those who have experienced a second trimester miscarriage or abortion should wait for at least six weeks before having a diaphragm fitted;
- Those who have recently given birth should wait until at least six weeks after childbirth to have a diaphragm fitted;
- Those with uterine abnormalities, including uterine prolapse. These women should discuss other contraceptive methods which might be more suitable with their healthcare provider so that they can choose another method;
- Those with latex allergies should not use a latex diaphragm. A silicon diaphragm may be appropriate, or the woman’s healthcare provider will be able to give advice about other contraceptive methods.
In addition, a diaphragm should not be used by the following women
- Women with a history of toxic shock syndrome – as diaphragms increase the risk of this condition. Women who have previously experienced toxic shock syndrome should discuss other, more appropriate contraceptive methods with their healthcare provider. They should also not use a cervical cap);
- Women who have a high risk of HIV – as a diaphragm is typically and most effectively used in conjunction with spermicide, and commonly available spermicides increase the risk of HIV infection, diaphragm use may increase a woman’s HIV risk. Women who are at risk of HIV infection, for example those who have sex with partners whose HIV status is unknown, should use condoms if possible, as these reduce the risk of HIV infection and other sexually transmitted infections. (For some women find it is difficult to use condoms, for example if their partners refuse, there are pregnancy prevention methods which they can use without their partner’s knowledge including hormonal contraceptive injections or implants, or a diaphragm. However, these methods do not protect against STIs.)
The Sex in Australia survey, a national study of sexual experiences and behaviours of Australians, reported that 0.9% of Australian women used a diaphragm.
When used correctly and in conjunction with spermicide during every act of sexual intercourse, the diaphragm prevents pregnancy in 94% of cases. However, most women do not use the diaphragm correctly every time they have sex, and as typically used, its effectiveness is much lower, around 84%.
It is very important for a diaphragm user to know how to use the device correctly. The health practitioner who fits the diaphragm will explain to the woman how a diaphragm is used, when they do the fitting.
Your health practitioner may recommend that new users begin by using their diaphragm in conjunction with another method. This is not because diaphragms do not work when they are first fitted, but rather to allow the woman to get used to inserting and removing the device correctly.
Diaphragm users should also be aware that:
- For effective use, a diaphragm must be used prior to every act of intercourse;
- When a diaphragm is correctly inserted, the woman should not be able to feel it, even during intercourse;
- That diaphragms are most effective when used in conjunction with spermicides;
- That diaphragms have some side effects, the most common of which are urinary tract infections and vaginal discharges (see below).
Diaphragms must be fitted by a health professional. To select a diaphragm of the correct size, the health provider will conduct a pelvic examination. The health provider will first assess the woman’s uterine cavity for any conditions which may make the diaphragm an unsuitable contraceptive method for the woman. The practitioner will then insert their index and middle finger into the woman’s vagina to determine the required diaphragm size. A diaphragm will then be selected and inserted into the woman’s vagina by the health practitioner, so that it covers the cervix. The practitioner will then check that the device fits correctly.
Women using diaphragms should be aware that a new diaphragm must be fitted after childbirth or a second trimester abortion. A new diaphragm should also be fitted if the woman experiences weight gain of >5kg. Women who do not need to have a new diaphragm refitted should replace their device every two years.
The diaphragm must be inserted prior to each act of intercourse. The health practitioner who fits the device will explain to women who are new users of the diaphragm, how to use the device. They may also give the women additional information about her genital organs, which will assist her to correctly insert the device. For example the health practitioner may show women the position of the cervix and pubic bone, using a diagram or model.
To correctly insert a diaphragm a woman should:
- Begin by washing her hands;
- Check the diaphragm for cracks by holding it up to the light;
- Insert spermicide into the dome and around the rim of the diaphragm. It is important to always check the expiry date of spermicides before using them;
- Press the rims of the diaphragm together and insert the device deep into the vagina. The woman should choose a comfortable position for insertion, for example lying down;
- Insert her finger into her vagina and feel to check that the diaphragm is in the correct position, that it is covering the cervix. The cervix feels similar to the tip of the nose, and can be felt through the diaphragm;
- Remove and reinsert the diaphragm if she can feel it inside her vagina when she moves;
- If the woman has sexual intercourse several times, she should not remove and reinsert the diaphragm between sex acts. Rather the diaphragm should be left in place and additional spermicide added each time.
It is very important that the diaphragm is left in place for at least six hours following intercourse, but not for more than 24 hours. Leaving the diaphragm in place for more than 24 hours may result in unpleasant odour or vaginal discharge, and in rare cases, toxic shock syndrome. Once at least six hours has elapsed since the last sexual intercourse, a woman should remove the diaphragm according to the following procedure:
- Before commencing, the woman should wash her hands;
- She should then insert a finger into her vagina until she feels the rim of the diaphragm;
- She should gently slide the finger under the rim and pull the diaphragm down and out. Care should be taken to ensure the diaphragm does not tear or break;
- Finally, she should wash the diaphragm using mild soap and water. The diaphragm should then be dried and stored in a cool dry place.
Benefits of the diaphragm include:
- Use of a diaphragm is controlled by the woman and can be used without the knowledge or consent of her male partner;
- A diaphragm is effective even if it is inserted up to six hours before intercourse and thus can be inserted in advance to avoid disrupting sexual activity;
- Using a diaphragm may enable a woman to become more familiar with her genital organs, for example she will learn where her cervix is, and become more comfortable inserting her fingers into her vagina;
- The diaphragm is a relatively low cost contraceptive method, which does not require frequent visits to a medical practitioner.
Diaphragm use is commonly associated with urinary tract infections. This means that between 1-10% of users experience this side effects.
Candidiasis and bacterial vaginosis are uncommon side effects of diaphragm use, that is, they are side effects experienced by between 0.1%-1% of women who use the device. When the diaphragm is used in conjunction with a spermicide, these side effects are more likely.
Very rare cases of toxic shock syndrome have been reported in diaphragm users. Less that 0.01% of users experience this side effect.
Limitations of the diaphragm include:
- The diaphragm must be inserted prior to every act of intercourse;
- The contraceptive protection of a diaphragm is much less effective than other methods (e.g. hormonal methods are typically >99% effective);
- To insert a diaphragm a woman must be comfortable with inserting her finger/s into her vagina. Women who have cultural or other objections to touching their genitals cannot use the method;
- Diaphragms do not provide adequate protection against sexually transmitted infections (STI). Women who have sexual partners of unknown STI status, should use male or female condoms if this is possible. Condoms offer high levels of protection against both pregnancy and STI.
|For more information on different types of contraception, female anatomy and related health issues, see Contraception.|
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- World Health Organisation. Family Planning: A global handbook for providers. 2007. [cited 2009, June 20] Available from: www.who.int/entity/reproductivehealth/publications/family_planning/en/
- Amy, J. Tripathi, V. Contraception for women: an evidence based review. BMJ. 2009. 339:563-8.
- Farmer, L. Everett, S. Nonhormonal contraception. Obstetric, gynaecological and reproductive medicine. 2007.18(2):33-8.
- Richters, J. Grulich, A.E. de Visser, R.O. et al. Sex in Australia: Contraceptive Practices in a representative sample of women. Aust NZ J Pub Health. 2003;27:210-6.