Diaphragm (contraceptive)

intercourse or bowel movements.[3] It is also more likely

that a womans partner will feel the anterior rim of a toosmall diaphragm during intercourse. A diaphragm that
is too large will place pressure on the urethra, preventing
the bladder from emptying completely and increasing the
risk of urinary tract infection.[3] A too-large diaphragm
may also rub a sore on the vaginal wall.[7]

The diaphragm is a cervical barrier type of birth control.

It is a soft latex or silicone dome with a spring molded into
the rim. The spring creates a seal against the walls of the
vagina.

Use

Diaphragms should be re-tted after a weight change of

[4]
Upon inserting or removing a diaphragm, one should rst 4.5 kg (10 lb) or more. The traditional clinical guideline
wash their hands[2] to avoid introducing harmful bacteria is that a decrease in weight may cause a woman to need a
larger size, although the strength of this relationship has
into the vaginal canal.
been questioned.[8]
The rim of a diaphragm is squeezed into an oval or arc
be re-tted after any pregnancy
shape for insertion. A water-based lubricant (usually Diaphragms should also
[2]
of
14
weeks
or
longer.
Full-term vaginal delivery espespermicide) may be applied to the rim of the diaphragm
cially
will
tend
to
increase
the size diaphragm a woman
to aid insertion. One teaspoon (5 mL) of spermicide may
needs,
although
the
changes
to the pelvic oor during
be placed in the dome of the diaphragm before insertion,
pregnancy
mean
even
women
who experience second[3]
or with an applicator after insertion.
trimester miscarriage, or deliver by C-section, should be
The diaphragm must be inserted sometime before sexual retted.
intercourse, and remain in the vagina for 6 to 8 hours
after a mans last ejaculation.[4] For multiple acts of in- Vaginal tenting, an increase in the length of the vagina,
tercourse, it is recommended that an additional 5 mL occurs during arousal. This means that during interof spermicide be inserted into the vagina (not into the course, the diaphragm will not t snugly against the pubic
domethe seal of the diaphragm should not be broken) bone because it is carried higher up the vaginal canal by
before each act. Upon removal, a diaphragm should be the movement of the cervix. If the diaphragm is inserted
be taken to encleansed with warm mild soapy water before storage. The after arousal has begun, extra care must
[5]
sure
the
device
is
covering
the
cervix.
diaphragm must be removed for cleaning at least once every 24 hours[3] and can be re-inserted immediately.
A woman might be tted with a dierent size diaphragm
Oil-based products should not be used with latex di- depending on where she is in her menstrual cycle. It is
aphragms. Lubricants or vaginal medications that con- common for a woman to wear a larger diaphragm during
tain oil will cause the latex to rapidly degrade and greatly menstruation. It has been speculated that a woman may
a larger size diaphragm when she is near
increases the chances of the diaphragm breaking or be tted with
ovulation.[9] The correct size for a woman is the largest
tearing.[4]
size that she can wear comfortably throughout her cycle.
Natural latex rubber will degrade over time. Depending on usage and storage conditions, a latex diaphragm In the United States, diaphragms are available by
should be replaced every one[5] to three[6] years. Silicone prescription only. Many other countries do not require
prescriptions.
diaphragms may last much longerup to ten years.

3 Mechanism of contraception

Fitting

Diaphragms come in dierent sizes. A tting appoint- The spring in the rim of the diaphragm forms a seal
ment with a health care professional is necessary to de- against the vaginal walls. The diaphragm covers the
cervix, and physically prevents sperm from entering the
termine which size a woman should wear.
A correctly tting diaphragm will cover the cervix and uterus through the os.
rest snugly against the pubic bone. A diaphragm that is Traditionally, the diaphragm has been used with spermitoo small might t inside the vagina without covering the cide, and it is widely believed the spermicide signicantly
cervix, or might become dislodged from the cervix during increases the eectiveness of the diaphragm. Insucient
1

TYPES

studies have been conducted to determine eectiveness ply choose to have intercourse without placing the diwithout spermicide.[10]
aphragm.
It is widely taught that additional spermicide must be
placed in the vagina if intercourse occurs more than six
hours after insertion.[2][5] However, there has been very
little research on how long spermicide remains active
within the diaphragm. One study found that spermicidal jelly and creme used in a diaphragm retained its full
spermicidal activity for twelve hours after placement of
the diaphragm.[11]
It has long been recommended that the diaphragm be left
in place for at least six or eight hours after intercourse.
No studies have been done to determine the validity of
this recommendation, however, and some medical professionals have suggested intervals of four hours[12] or
even two hours[13] are sucient to ensure ecacy. Interestingly, one manufacturer of contraceptive sponges only
recommends leaving the sponge in place for two hours after intercourse.[14] However, such use of the diaphragm
(removal before 6 hours post-intercourse) has never been
formally studied, and cannot be recommended.

Contraceptive Technology reports that the method failure

rate of the diaphragm with spermicide is 6% per year.[16]
The actual pregnancy rates among diaphragm users vary
depending on the population being studied, with yearly
rates of 10%[17] to 39%[18] being reported.
Unlike some other cervical barriers, the eectiveness of
the diaphragm is the same for women who have given
birth as for those who have not.[19]

5 Types
Diaphragms are available in diameters of 50mm to
105mm (about 2-4 inches). They are available in two
dierent materials: latex (currently manufactured by Reexions) and silicone (currently manufactured by Ortho,
Milex and Semina). Diaphragms are also available with
dierent types of springs in the rim.[20]

It has been suggested that diaphragms be dispensed as

a one-size-ts-all device, providing all women with the
most common size (70mm). However, only 33% of
women tted for a diaphragm are prescribed a 70mm
size, and correct sizing of the diaphragm is widely considered necessary.[15]

Eectiveness

The eectiveness of diaphragms, as of most forms of

contraception, can be assessed two ways: method eectiveness and actual eectiveness. The method eectiveness is the proportion of couples correctly and consistently using the method who do not become pregnant.
Actual eectiveness is the proportion of couples who intended that method as their sole form of birth control and
do not become pregnant; it includes couples who sometimes use the method incorrectly, or sometimes not at
all. Rates are generally presented for the rst year of use.
Most commonly the Pearl Index is used to calculate effectiveness rates, but some studies use decrement tables. An arcing spring diaphragm in its case, with quarter added to
For all forms of contraception, actual eectiveness is photograph for scale.
lower than method eectiveness, due to several factors:
An arcing spring folds into an arc shape when the sides are
compressed. This is the strongest type of rim available in
mistakes on the part of those providing instructions
a diaphragm, and may be used by women with any level
on how to use the method
of vaginal tone. Unlike other spring types, arcing springs
may be used by women with mild cystocele, rectocele, or
mistakes on the part of the methods users
retroversion.[21] Arcing spring diaphragms may be easier
to insert correctly than other spring types.[22] Examples
conscious user non-compliance with method
of arcing spring diaphragms are the Ortho All-Flex and
For instance, someone using a diaphragm might be tted the Milex Wide-Seal Arcing.
incorrectly by a health care provider, or by mistake re- A coil spring attens into an oval shape when the sides are
move the diaphragm too soon after intercourse, or sim- compressed. This rim is not as strong as the arcing spring,

3
and may only be used by women with average or rm
vaginal tone.[3] If an arcing spring diaphragm is uncomfortable for a woman or, during intercourse, her partner,
a coil spring may prove more satisfactory. Unlike the arcing spring diaphragms, coil springs may be inserted with
a device called an introducer. Examples of coil spring diaphragms are the Ortho Coil, the Milex Wide-Seal Omniex, and the Semina diaphragm.

Because pelvic inammatory disease (PID) is caused by

certain STIs, diaphragms may lower the risk of PID.[25]
Cervical barriers may also protect against human papillomavirus (HPV), the virus that causes cervical cancer,
although the protection appears to be due to the spermicide used with diaphragms and not the barrier itself.[26]

Diaphragms are also considered a good candidate as

a delivery method for microbicides (preparations that,
A at spring is much like a coil spring, but thinner. This used vaginally, protect against STIs) that are currently in
type of rim may only be used by women with rm vaginal development.[6]
tone. Flat spring diaphragms may also be inserted with an
introducer for women uncomfortable using their hands.[3]
Ortho used to manufacture a at-spring diaphragm called 7 Risks
the Ortho White.[23] While some providers may still have
Ortho White diaphragms in stock, the only current manufacturer of a at-spring diaphragm is Reexions.[20][21] Women (or their partners) who are allergic to latex should
not use a latex diaphragm.
Variations on the traditional diaphragm are being tested.
The SILCS diaphragm is made of silicone, has an arc- Diaphragms are associated with an increased risk of
[27]
Urinating before inserting spring, and a nger cup is molded on one end for urinary tract infection (UTI)
ing
the
diaphragm,
and
also
after
intercourse, may reduce
easy removal. The Duet disposable diaphragm is made of
[2]
this
risk.
dipped polyurethane, pre-lled with BuerGel (BuerGel is currently in clinical trials as a spermicide and Toxic shock syndrome (TSS) occurs at a rate of 2.4 cases
microbicide).[20] Both the SILCS and Duet diaphragms per 100,000 women using diaphragms, almost exclusively
are one-size-ts-all.
when the device is left in place longer than 24 hours.[3]

Advantages

The diaphragm does not interfere with a womans natural

cycle, therefore, no reversal or wait time is necessary, if
contraception is no longer wanted or needed.
The diaphragm only has to be used during intercourse.
Many women, especially those who have sex less frequently, prefer barrier contraception such as the diaphragm over methods that require some action every
day.[2]

The increase in risk of UTIs may be due to the diaphragm applying pressure to the urethra, especially if
the diaphragm is too large, and causing irritation and
preventing the bladder from emptying fully. However,
the spermicide nonoxynol-9 is itself associated with increased risk of UTI, yeast infection, and bacterial vaginosis.[28] For this reason, some advocate use of lactic
acid or lemon juice based spermicides, which might have
fewer side eects.[29] Although these alternative spermicides have been shown to immobilize sperm in the laboratory, their eect on pregnancy rates in humans has never
been studied.

It has also been suggested that, for women who experience side eects from nonoxynol-9, it may be acceptable
to use the diaphragm without any spermicide. One study
found an actual pregnancy rate of 24% per year in women
using the diaphragm without spermicide; however, all
The diaphragm is less expensive than many other methods women in this study were given a 60mm diaphragm rather
of contraception.[3]
than being tted by a clinician.[30] Other studies have
been small and given conicting results.[31][32] The current recommendation is still for all diaphragm users to
6.1 Protection from sexually transmitted use spermicide with the device.[10]
Like all cervical barriers, diaphragms may be inserted
several hours before use, allowing uninterrupted foreplay
and intercourse. Most couples nd that neither partner
can feel the diaphragm during intercourse.

infections

There is some evidence that the cells in the cervix are particularly susceptible to certain sexually transmitted infections (STIs). Cervical barriers such as diaphragms may
oer some protection against these infections.[6] However, research conducted to test whether the diaphragm
oers protection from HIV found that women provided
with both male condoms and a diaphragm experienced
the same rate of HIV infection as women provided with
male condoms alone.[24]

8 History
The idea of blocking the cervix to prevent pregnancy
is thousands of years old. Various cultures have used
cervix-shaped devices such as oiled paper cones or lemon
halves, or have made sticky mixtures that include honey
or cedar rosin to be applied to the cervical opening.[33]
However, the diaphragmwhich stays in place because

4
of the spring in its rim, rather than hooking over the
cervix or being stickyis of much more recent origin.
An important precursor to the invention of the diaphragm
was the rubber vulcanization process, patented by Charles
Goodyear in 1844. In the 1880s, a German gynecologist, Wilhelm P. J. Mensinga, published the rst description of a rubber contraceptive device with a spring
molded into the rim. Wilhelm P. J. Mensinga (18361910) wrote rst under the pseudonym C. Hasse and the
Mensinga diaphragm was the only brand available for
many decades.[34][35][36] In the United States, the physician Edward Bliss Foote designed and sold an early form
of occlusive pessary under the name "womb veil" starting
in the 1860s.[37]
American birth control activist Margaret Sanger ed
to Europe in 1914 to escape prosecution under the
Comstock laws, which prohibited sending contraceptive devices, or information about contraception, through
the mail. Sanger learned about the diaphragm in the
Netherlands and introduced the product to the United
States when she returned in 1916. Sanger and her second husband, Noah Slee, illegally imported large quantities of the devices from Germany and the Netherlands.
In 1925, Slee provided funding to Sangers friend Herbert
Simonds, who used the funds to found the rst diaphragm
manufacturing company in the U.S., the Holland-Rantos
Company.[33][38]
Diaphragms played a role in overturning the federal Comstock Act. In 1932, Sanger arranged for a Japanese manufacturer to mail a package of diaphragms to a New York
physician who supported Sangers activism. U.S. customs
conscated the package, and Sanger helped le a lawsuit.
In 1936, in the court case United States v. One Package
of Japanese Pessaries, a federal appellate court ruled that
the package could be delivered.[33]
Although in Europe, the cervical cap was more popular
than the diaphragm, the diaphragm became one of the
most widely used contraceptives in the United States. In
1940, one-third of all U.S. married couples used a diaphragm for contraception. The number of women using diaphragms dropped dramatically after the 1960s introduction of the IUD and the combined oral contraceptive pill. In 1965, only 10% of U.S. married couples
used a diaphragm for contraception.[36] That number has
continued to fall, and in 2002 only 0.2% of American
women were using a diaphragm as their primary method
of contraception.[39] Diaphragms, both the Ortho brand
and Reexions, and the spermicidal gel used with them,
can be purchased online. There is an e-mail community
of users, where resources may be found, as well as tips
on making ones own homemade spermicide, to be used
with a barrier method.[40]

10 FOOTNOTES

9 See also
Reproductive Health Supplies Coalition

10 Footnotes
[1] Trussell, James (2011). Contraceptive ecacy. In
Hatcher, Robert A.; Trussell, James; Nelson, Anita L.;
Cates, Willard Jr.; Kowal, Deborah; Policar, Michael S.
(eds.). Contraceptive technology (20th revised ed.). New
York: Ardent Media. pp. 779863. ISBN 978-1-59708004-0. ISSN 0091-9721. OCLC 781956734. Table 261
= Table 32 Percentage of women experiencing an unintended pregnancy during the rst year of typical use and
the rst year of perfect use of contraception, and the percentage continuing use at the end of the rst year. United
States.
[2] Johnson, Jennifer (December 2005). Diaphragms, Caps,
and Shields. Planned Parenthood. Retrieved 2006-1015.
[3] Allen, Richard (January 2004). Diaphragm Fitting.
American Family Physician (American Academy of Family Physicians) 69 (1): 97100. PMID 14727824. Retrieved 2006-10-15.
[4] Diaphragm. Feminist Womens Health Center. January
2006. Retrieved 2006-10-15.
[5] After your doctor or health care provider prescribes your
Ortho diaphragm (PDF) (Press release). Ortho-McNeil
Pharmaceutical. 2004. Retrieved 2007-07-22.
[6] S. Marie Harvey, Sheryl Thorburn Bird and Meredith
Roberts Branch (NovemberDecember 2004). A New
Look at an Old Method: The Diaphragm. Perspectives on Sexual and Reproductive Health 35 (6): 2703.
doi:10.1363/3527003. PMID 14744659.
[7] Diaphragms: Management of Side Eects. PocketGuide for Family Planning Service Providers: Barriers and
Spermicides. Reproductive Health Online. 2003. Retrieved 2007-09-15.
[8] Kugel C, Verson H; Verson (1986). Relationship between weight change and diaphragm size change. Journal of obstetric, gynecologic, and neonatal nursing :
JOGNN / NAACOG 15 (2): 1239. doi:10.1111/j.15526909.1986.tb01377.x. PMID 3517255.
Fiscella K (1982). Relationship of weight change to required size of vaginal diaphragm. The Nurse practitioner
7 (7): 21, 25. doi:10.1097/00006205-198207000-00004.
PMID 7121900.
[9] Weschler, Toni (2002). Taking Charge of Your Fertility
(Revised ed.). New York: HarperCollins. p. 232. ISBN
0-06-093764-5.

In 2014 Janssen Pharmaceuticals announced the discon- [10] Cook L, Nanda K, Grimes D; Nanda; Grimes
(2001).
Lopez, Laureen M, ed.
Diaphragm
tinuation of the Ortho-All Flex Diaphragm, making it
versus
diaphragm
with
spermicides
for
contracepvery dicult for women in the US to have that option
tion.
Cochrane
Database
Syst
Rev
(2):
CD002031.
as a birth-control method.[41]
doi:10.1002/14651858.CD002031. PMID 11406025.

[11] Leitch W (1986). Longevity of Ortho Creme and Gynol II in the contraceptive diaphragm. Contraception
34 (4): 38193. doi:10.1016/0010-7824(86)90090-9.
PMID 3780236.
[12] Kovacs G (1990). Fitting a diaphragm. Aust Fam Physician 19 (5): 713, 716. PMID 2346425.
[13] Bernstein G (1977). Is eectiveness of diaphragm compromised by postcoital swimming or bathing?". JAMA
237 (3): 270. doi:10.1001/jama.237.24.2643. PMID
12259737.
[14] Sponges. Cervical Barrier Advancement Society. 2004.
Retrieved 2006-09-17.
[15] Mauck C, Lai J, Schwartz J, Weiner D; Lai; Schwartz;
Weiner (2004). Diaphragms in clinical trials: is clinician tting necessary?". Contraception 69 (4): 263
6. doi:10.1016/j.contraception.2003.11.006. PMID
15033398.
[16] Hatcher, RA; Trussel J; Stewart F et al. (2000).
Contraceptive Technology (18th ed.). New York: Ardent
Media. ISBN 0-9664902-6-6.
[17] Bulut A, Ortayli N, Ringheim K, Cottingham J, Farley T, Peregoudov A, Joanis C, Palmore S, Brady M,
Diaz J, Ojeda G, Ramos R; Ortayli; Ringheim; Cottingham; Farley; Peregoudov; Joanis; Palmore; Brady;
Diaz; Ojeda; Ramos (2001). Assessing the acceptability, service delivery requirements, and use-eectiveness
of the diaphragm in Colombia, Philippines, and Turkey.
Contraception 63 (5): 26775. doi:10.1016/S00107824(01)00204-9. PMID 11448468.
[18] Kippley, John; Sheila Kippley (1996). The Art of
Natural Family Planning (4th addition ed.). Cincinnati,
Ohio: The Couple to Couple League. p. 146. ISBN
0-926412-13-2., which cites:
Guttmacher Institute (1992). Choice of
Contraceptives. The Medical Letter on
Drugs and Therapeutics 34 (885): 111114.
PMID 1448019.
[19] Trussell J, Strickler J, Vaughan B; Strickler; Vaughan
(1993). Contraceptive ecacy of the diaphragm, the
sponge and the cervical cap. Fam Plann Perspect 25 (3):
1005, 135. doi:10.2307/2136156. JSTOR 2136156.
PMID 8354373.
[20] Diaphragms. Cervical Barrier Advancement Society.
2000. Retrieved 2006-10-18.

[24] QUESTIONS & ANSWERS: The MIRA Diaphragm

Trial Results (DOC). Cervical Barrier Advancement Society. July 2007. Retrieved 2007-07-22.
[25] J, Kelaghan; G.L. Rubin, H.W. Ory and P.M. Layde (July
1982). Barrier-method contraceptives and pelvic inammatory disease. Journal of the American Medical Association 248 (2): 184187. doi:10.1001/jama.248.2.184.
PMID 7087109.
[26] Hildesheim A, Brinton L, Mallin K, Lehman H, Stolley
P, Savitz D, Levine R; Brinton; Mallin; Lehman; Stolley; Savitz; Levine (1990). Barrier and spermicidal contraceptive methods and risk of invasive cervical cancer.
Epidemiology 1 (4): 26672. doi:10.1097/00001648199007000-00003. PMID 2083303.
[27] Fihn S, Latham R, Roberts P, Running K, Stamm W;
Latham; Roberts; Running; Stamm (1985). Association between diaphragm use and urinary tract infection.
JAMA 254 (2): 2405. doi:10.1001/jama.254.2.240.
PMID 3999367.
Heaton C, Smith M; Smith (1989). The diaphragm. Am
Fam Physician 39 (5): 2316. PMID 2718900.
[28] Drug Information: Nonoxynol-9 cream, lm, foam, gel,
jelly, suppository. Medical University of South Carolina.
March 2006. Retrieved 2006-08-06.
[29] Natural Spermicides and Femprotect. Ovusoft.com
Message Boards. June 2003. Retrieved 2006-10-17.
|rst1= missing |last1= in Authors list (help)
Femprotect - Lactic Acid Contraceptive Gel. Womans
Natural Health Practice. Archived from the original on
2006-06-01. Retrieved 2006-09-17.
[30] Nonspermicide t-free diaphragm trial reported. Network 5 (3): 7. 1984. PMID 12279800.
[31] Ferreira A, Arajo M, Regina C, Diniz S, Fandes A;
Arajo; Regina; Diniz; Fandes (1993). Eectiveness
of the diaphragm, used continuously, without spermicide. Contraception 48 (1): 2935. doi:10.1016/00107824(93)90063-D. PMID 8403903.
[32] Bounds W, Guillebaud J, Dominik R, Dalberth B; Guillebaud; Dominik; Dalberth (1995). The diaphragm with
and without spermicide. A randomized, comparative efcacy trial. J Reprod Med 40 (11): 76474. PMID
8592310.
[33] A History of Birth Control Methods. Planned Parenthood. June 2002. Retrieved 2010-12-16.

[21] Diaphragms. Ortho Womens Health. Ortho-McNeil

Pharmaceutical. 2001. Retrieved 2006-10-18.

[34] ber die facultative Sterilitt vom prophylaktischen und

hygienischen Standpunkt (Pseudonym C. Hasse), Verlag
Louis Heuser, Neuwied/Berlin 1882

[22] Women nd arcing-spring diaphragm easier to insert,

studies indicate. Contracept Technol Update 7 (4): 412.
1986. PMID 12340681.

[35] Aus dem rztlichen Leben. Ratgeber fr angehende und

junge rzte (Pseudonym C.Hasse), Verlag Otto Borghold,
1886

[23] Contraceptive Diaphragm. Family Practice Notebook.

2000. Archived from the original on 2006-09-02. Retrieved 2006-10-18.

[36] Evolution and Revolution: The Past, Present, and Future

of Contraception. Contraception Online (Baylor College
of Medicine) 10 (6). February 2000.

12

[37] Robert Jtte, Contraception: A History (Polity Press,

2008, originally published in German 2003), p. 154; Andrea Tone, Devices and Desires: A History of Contraceptives in America (MacMillan, 2001), p. 57 online;
[38] Biographical Note. The Margaret Sanger Papers.
Northampton, Mass: Sophia Smith Collection, Smith
College. 1995. Retrieved 2006-10-21.
[39] Chandra, A; Martinez GM; Mosher WD; Abma JC; Jones
J. (2005). Fertility, Family Planning, and Reproductive
Health of U.S. Women: Data From the 2002 National
Survey of Family Growth (PDF). Vital and Health Statistics (National Center for Health Statistics) 23 (25). Retrieved 2007-05-20. See Table 56.
[40] Karneef, Natalie (2011-01-18). What if you don't want
to take 'the pill'?". Montreal Gazette. Retrieved 2011-0209.
[41] Ortho Diaphragm Discontinued | The Blog That Ate Manhattan

11

Further reading

Halberstam, David (1994). The Fifties. New York:

Fawcett Columbine.
McCann, Carole R. (1994). Birth Control Politics in
the United States, 19161945. Ithaca: Cornell University Press.
Tobin, Kathleen (2001). The American Religious
Debate Over Birth Control, 19071937. Jeerson:
McFarland & Company.

12

External links

Cervical Barrier Advancement Society

DiaphragmsAndCaps Yahoo! group "For women
using or considering a barrier"
Kara Sutra from BLIP TV demonstrates the proper
usage and application of a diaphragm

EXTERNAL LINKS

13
13.1

Text and image sources, contributors, and licenses

Text

Diaphragm (contraceptive) Source: http://en.wikipedia.org/wiki/Diaphragm_(contraceptive)?oldid=651986048 Contributors: Scipius,

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WayneMokane, Kelly Martin, Mathmo, Graham87, Rjwilmsi, Zakolantern, Brighterorange, FlaBot, Robojames, Chobot, Jared Preston,
Neitherday, RussBot, Icarus3, Lexi Marie, Mbellavia, Chooserr, M3taphysical, Naught101, Lyrl, Sardanaphalus, SmackBot, C.Fred, Bomac, Ceridwen~enwiki, Gilliam, Betacommand, Uthbrian, Colonies Chris, Maxk~enwiki, OhadAston, Bistroboy9829, Giancarlo Rossi,
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13.2

Images

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