The diaphragm: barrier contraception has a new social role

Abstract

Using a diaphragm as a barrier contraceptive has received little attention in recent literature. A discussion of the role of the diaphragm to prevent pregnancy, as well as sexually transmitted diseases, is presented. A procedure for properly fitting the diaphragm is described. To ensure compliance, a review of a plan for education and practice by users is outlined.

PIP: The vaginal diaphragm, while designed for contraception, provides important additional benefits as a barrier to the transmission of sexually transmitted diseases (STDs). For centuries women have used various forms of the diaphragm to prevent pregnancy (e.g., cups molded of opium or oiled silky paper or halves of squeezed lemons). The modern diaphragm was brought to the US from Europe by Margaret Sanger in the 1920s. Today, three types are available: arcing, coil, and flat spring. Typical use of the diaphragm may provide greater efficacy than other barrier methods. The spermicidal agent used in conjunction with the diaphragm, nonoxynol-9, is active against a wide range of bacterial and parasite-associated STDs (but no data prove that spermicides are active against HIV in vivo). Thus, women using barrier contraceptives have lower prevalence rates of STDs and are less likely to develop cervical cancer or its precursors. The diaphragm also has no systemic side effects. However, diaphragm use has been associated with increased incidence of candidal infections, urinary tract infections, and bacterial vaginosis. Diaphragm use increased between 1973 and 1982, and efficacy is determined by the user's knowledge and consistency of use. First-year failure rates have been noted in 18% of those who exhibit typical use and 6% in cases of perfect use. Failure rates determine acceptance as does cost, which in the case of the diaphragm ranges from $18 to $30 in the US with spermicidal jelly costing $6-13 per tube. Diaphragms must be prescribed and fitted by a health care provider. They can be inserted 6 hours before intercourse and must remain in place for 6 hours thereafter. The only absolute contraindication to diaphragm use occurs in women in whom pregnancy would be life-threatening. Women depending on hormonal methods for contraception should consider use of the diaphragm for prevention of STDs. Diaphragm sizes range from 50 to 95 mm, and fit is determined by the distance between the posterior fornix and the pubic bone. Clients must be taught proper insertion and use techniques through an initial 30-minute visit and, ideally, in a follow-up visit 2 weeks later. Diaphragms should be replaced every 3 years or immediately should the diaphragm become punctured.