Fitting Contraceptive Diaphragms

Sandra M. Sulik, MD, MS, FAAFP
Email

Send Email

Recipient(s) will receive an email with a link to 'Fitting Contraceptive Diaphragms' and will have access to the topic for 7 days.

Subject: Fitting Contraceptive Diaphragms

(Optional message may have a maximum of 1000 characters.)

×


Introduction

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. 
Latex diaphragms are available by prescription from most pharmacies. Silicone diaphragms must be ordered from the manufacturer. They range in size from 50 to 105 mm in diameter; the 65- to 80-mm sizes are the 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 a 20-lb weight gain or loss, and annually. Avoid devices that are too large (i.e., uncomfortable or press excessively on the urethra) 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 can be ordered in silicone (Milex) or latex (Ortho). The latex-allergic patient should use the silicone diaphragm only. 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. Use of a spermicide with the diaphragm is recommended, although studies have failed to prove that spermicide enhances the effectiveness of the diaphragm. Additional spermicide must be applied intravaginally with an applicator 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. 

Equipment

  • Items for a gynecologic examination (Appendix H: Instruments and Materials in a Standard Gynecological Tray)

  • Diaphragm fitting rings or diaphragms for fitting

Indications

  • Nonhormonal, reversible contraception

  • Intolerance to hormonal contraception

  • Desire for sexually transmitted disease (STD) protection

Contraindications

  • Vaginal stenosis

  • Uterine prolapse

  • History of toxic shock syndrome

  • Congenital vaginal abnormalities (septum)

  • Patient <6 weeks postpartum

  • Vaginal cysts

  • Use of petroleum-based products that may damage latex diaphragms

  • Drug allergies to the spermicides

The Procedure

Step 1

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. 

Step 2

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. 

Step 3

Insert the diaphragm after using a water-soluble lubricant on the rim of the device. Fold the device in half, spread the labia open, and the insert the device in a downward fashion toward the posterior fornix. The diaphragm will spring open. Check placement by sweeping the finger around the rim of the diaphragm to ensure it completely covers the cervix and reaches the posterior fornix. The anterior rim should be one finger’s breadth from the symphysis pubis. 
  • PEARL: Check size by trying a larger or smaller diaphragm and compare the fit.

  • PITFALL: Discomfort or excessive pressure on the urethra indicates the device is too large, and a device that is easily displaced or expelled is probably too small.

  • 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.

Step 4

The diaphragm is removed by hooking the index finger under the ring behind the symphysis and pulling. 
  • PEARL: When properly fitted, the patient should not feel any discomfort and should be comfortable during intercourse.

  • PITFALL: Caution the patient not to puncture the diaphragm with a long or ragged fingernail.

Step 5

The woman should 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. 

Step 6

Teach the patient to hold the diaphragm up to the light to look for holes, so she can do it every time she plans to insert the diaphragm. 

Complications

  • Increased risk of urinary tract infection

  • Toxic shock syndrome: 2.4 cases per 100,000 women (occurs almost exclusively when the diaphragm has been left in place >24 hours)

Pediatric Considerations

This procedure is not used in children. Although not commonly used in adolescents, the procedure is the same. 

Postprocedure Instructions

The patient should be comfortable inserting and removing her diaphragm before she leaves the office. She should also be instructed to place approximately 1 teaspoon of spermicidal jelly in the dome of the diaphragm before insertion and that she can use a small amount of spermicidal jelly on the rim as a lubricant. She should be reminded that the diaphragm can be inserted any time before intercourse but it must stay in place for a minimum of 6 hours and up to 24 hours after intercourse. If repeated acts of intercourse occur, additional spermicide should be placed in the vagina but the diaphragm should not be taken out before the 6 hours. The patient should also be comfortable checking the diaphragm to make sure it is inserted properly and that her cervix can be felt through the dome of the cervix. Once the diaphragm is removed, it should be washed with soap and water and stored in the plastic case. 

Coding Information and Supply Sources

Suppliers

Diaphragms (e.g., Ortho-flex) are dispensed by prescription from pharmacies. 
Fitting rings or diaphragm-fitting kits may be obtained from Ortho-McNeil Pharmaceuticals: 
  • Ortho-McNeil Pharmaceutical Company, 1000 Route 202 South, Raritan, NJ 08869-0602. Phone: 1-800-682-6532. Web site: http://www.ortho-mcneil.com.

Silicone diaphragms: 
  • Milex Products, Inc., 4311 N. Normandy, Chicago, IL 60634. Phone: 1-800-621-1278; fax: 1-800-972-0696. Web site: http://www.milexproducts.com.

Bibliography

Allen RE. Diaphragm fitting. Amer Fam Physician .  2004;69(1):97–100. [View Abstract]
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. [View Abstract]
Cook L, Nanda K, Grimes D, et al. Diaphragm versus diaphragm with spermicides for contraception. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002031. DOI: 10. 1002/14651858. CD002031.
DelConte A. Contraception. In: Curtis MG, Hopkins MP, Overholt S, eds. Glass’s Office Gynecology . 6th ed. Philadelphia: Lippincott Williams & Wilkins;  2006:347–383.
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. [View Abstract]
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. [View Abstract]
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. [View Abstract]
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. [View Abstract]
Speroff L, Darney P. A Clinical Guide for Contraception . 2nd ed. Baltimore: Williams & Wilkins;  1996.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
×