Our Bodies, Ourselves (48 page)

5.
Push the lower rim with your index or middle finger until you feel the diaphragm fit into place. When the diaphragm is in right and fits properly, you should not be able to feel it at all.

Leave the diaphragm in for at least six hours after intercourse. You can leave it in for up to twenty-four hours, but not longer.

If you have intercourse again, add more cream or jelly with an applicator. Put it into your vagina, leaving the diaphragm in place at least six hours after the last act of intercourse.

Choose a comfortable position, slide a finger into your vagina, and hook it under the lower rim of the diaphragm, either between the diaphragm and your vaginal wall or over the rubber dome. Pull the diaphragm forward and down.

© Nina Reimer

Insertion of diaphragm

Wash the diaphragm with mild soap and warm water, rinse and dry it carefully, and put it into a container (away from light). Do not boil it. To make sure the diaphragm is still effective, check its condition by holding it up to the light or filling it with water to check for holes. Oil-based creams, including some vaginal medications, can damage diaphragms, so avoid contact with those materials.

Get your diaphragm size rechecked after giving birth, after method failure, if you gain or lose more than ten pounds, or after any vaginal surgery. Diaphragms should be replaced every three years.

Getting a diaphragm requires a fitting by a health-care provider. Because diaphragms are not widely used, you should call ahead to make sure your provider knows how to fit you for a diaphragm and has the proper equipment to do so.

When you have been measured and fitted, practice putting the diaphragm in and taking it out before you leave the practitioner's office, so she or he can tell you whether you are doing it right. (Or go home, practice, and come back in a few days with the diaphragm in place.) Reach in and see what it feels like when it is in correctly, and get help immediately if you have problems,
so that when you actually use it, you won't be experimenting. The practitioner should have the diaphragm available right there or will give you a prescription for the proper size.

Some women cannot use a diaphragm because it can't be made to fit properly. Because diaphragms require manual dexterity, women with physical disabilities like arthritis might not be able to use them effectively without assistance. Women with chronic urinary tract infections or a history of toxic shock syndrome should not use a diaphragm.

•
If a woman uses the diaphragm without spermicide, will it work at all?
It might provide some protection, but using a diaphragm without spermicide reduces its effectiveness.

•
Is it okay to leave a diaphragm in all day?
Yes. After intercourse, a diaphragm must be left in for at least six hours to make sure that live sperm do not get past the barrier. Sperm will die in the vagina. After that time, remove and wash the diaphragm.

•
Can a woman use lubricants with a diaphragm?
As with condoms, use only water- or silicone-based lubricants, because oil-based lubricants can damage the latex rubber of the diaphragm. Often, the spermicide itself provides lubrication.

The cervical cap is a small cup-shaped silicone cap that fits snugly over the cervix (the entrance to the uterus) and is held in place by suction. The cervical cap is used with a spermicidal cream or jelly to immobilize sperm and prevent them from fertilizing an egg.

There is currently one cervical cap available in the United States, called the FemCap. It comes in three sizes and must be fitted by a provider. It has a loop for easy removal.

For women who have never given birth, the FemCap is 86 percent effective. For women who have given birth, the cap is 71 percent effective.
4
The cap is less effective for women in the first year after pregnancy.

These are the same as
for diaphragms
.

The effectiveness of a cervical cap depends on its fit as well as consistent and correct usage. The FemCap comes in different sizes and needs to be fitted by a medical practitioner, who will show you how to insert the cap. If you have questions, ask your practitioner or go to the website for FemCap (femcap.com). During the first few months of use, there is a higher risk of pregnancy. For better protection during this time, use a condom and check the position of the cap before and after intercourse to make sure it stays in place. If the cap moves during intercourse, consider using
emergency contraception
.

Inserting or removing a cervical cap is similar to using a diaphragm, but the cap does not fold. When the cap is properly in place, you should feel some resistance when you tug on the removal loop. (See the description of diaphragm
insertion and removal
.)

Care for a cervical cap is
similar to a diaphragm
. However, using oil-based lubricants will not damage the cap.

Giving birth can affect the way a cervical cap fits. Three months after a birth, have your medical provider check its fit.

The FemCap has the same health
concerns as diaphragms
.

Some women may experience an allergic reaction to the material of the cervical cap or the spermicide they use. If this happens, consider using another method of contraception.

Because most providers are not trained in fitting cervical caps, they are not widely available. However, they are available at many reproductive health clinics and from some other healthcare providers. Call the provider's office before your appointment to find out if the provider can fit a cervical cap.

The contraceptive sponge is a soft disk made of polyurethane that rests against the cervix during sex. The sponge contains the spermicide Nonoxynol-9 to immobilize sperm. It has a loop for easy removal.

For women who have never given birth, the perfect use effectiveness of the sponge is 91 percent; typical use effectiveness is 84 percent. For women who have given birth, the sponge is significantly less effective: 80 percent with perfect use and 68 percent with typical use.

Although the sponge can be purchased at pharmacies over the counter, the advantages and disadvantage are otherwise the same
as for diaphragms
.

Wet the sponge and insert it into your vagina, dimple side facing the cervix and loop side facing down. It is effective immediately. You can insert it up to twenty-four hours before sex and have intercourse multiple times while it is in place. The sponge must be left in place six hours after sex to be effective, but should not be left in the vagina longer than thirty hours. Throw the sponge away—do not flush—after use.

The health concerns for sponges are the same as
those for diaphragms
.

Some women may experience an allergic reaction to the material of the sponge or the spermicide in the sponge.

Sponges are available without a prescription at pharmacies and some reproductive health clinics.

Spermicides kill sperm so they cannot fertilize an egg to cause a pregnancy. The chemical Non-oxynol-9 (N-9) is the active ingredient in most spermicides, which are available in different forms: foam, jelly, cream, film, and suppositories. Spermicides are most effective when used consistently and correctly with a barrier method of birth control—a condom, diaphragm, or cervical cap. They give no protection against HIV; in fact,
some research indicates that Nonoxynol-9, when used more than once a day, can increase the risk of acquiring HIV.
5
However, spermicides containing N-9 are a safe contraceptive option for women at low risk for HIV/STIs who do not use the product more than once a day. (See
“Safety of Nonoxynol-9 When Used for Contraception”.
)

When used perfectly on their own, the different formulations of spermicides range in effectiveness from about 82 to 85 percent. With typical use, however, they are about 71 percent effective. As with all methods that depend on use with each act of intercourse, a spermicide's effectiveness varies widely depending on how correctly and consistently you use it. Spermicides are most effective when used with a barrier method such as a condom, diaphragm, or cervical cap.

• Available without a prescription.

• Lubrication may increase pleasure.

• Women who use N-9 more than once a day appear to have an increased risk of HIV transmission.

• Low typical use effectiveness.

• Can be messy.

• May make oral sex less pleasant.

• May irritate vulva or vagina and increase risk of urinary tract infection.

• Requires a brief pause.

Spermicides can be used alone or with a diaphragm, cervical cap, or condom to reduce the risk of pregnancy. Insert the spermicide within a half hour before intercourse. If it was inserted more than one hour before intercourse, it will have lost much of its effectiveness. Add more spermicide for repeated intercourse. Leave spermicide in your vagina for six hours after the last act of intercourse. Avoid douching in general, but if you must douche, wait at least six hours (douching washes away spermicide).

Foam comes in a can and is the consistency of shaving cream. It is inserted using an applicator that comes with the can and is effective immediately. Follow the manufacturer's instructions for use.

Creams and jellies are inserted into the vagina with an applicator and take effect immediately.

VCF comes as paper-thin squares that dissolve over the cervix. After it's inserted, it takes about fifteen minutes for the VCF to become effective. Follow the manufacturer's instructions for use.

Suppositories are inserted into the vagina like a tampon and pushed up toward the cervix. It takes about twenty minutes for the capsule to dissolve and become effective.

You or your partner may experience genital irritation, a rash, or itchiness if either of you is allergic to ingredients in a spermicide. If this happens, you may need to use another method of contraception.

Spermicides are available over the counter in any drugstore or can be bought in family-planning clinics or online.

If you become pregnant while using spermicide, the pregnancy will not be affected.

Hormonal contraceptives come in many forms—daily pills, weekly patches, monthly rings, and quarterly injections. They work by using hormones similar to the ones our bodies produce to prevent the release of eggs. Combined hormonal contraceptives use both estrogen and progestin. Progestin-only contraceptives do not contain estrogen.

For hormonal methods to work, you have to use them as directed and on schedule. They protect against pregnancy, but not against STIs, including HIV.

Menstrual bleeding—a period—is the result of the interaction of the hormones estrogen and progesterone in our bodies. Estrogen causes the lining of the uterus (the endometrium) to thicken in preparation for pregnancy; progesterone further develops the lining of the uterus and maintains it during pregnancy. If no pregnancy occurs in the cycle, there is a fall in progesterone, and the lining is shed. This lining is what is expelled during menstruation.

Hormonal contraceptives use synthetic hormones to suppress ovulation and prevent pregnancy. Most birth control pills contain some form of estrogen and a synthetic form of progesterone called a progestin. These hormones stabilize the uterine lining and encourage more regular bleeding patterns. Progestin-only methods such as Depo-Provera, implants, and some pills contain no estrogen. They can lead to irregular or absent bleeding.

These changes in bleeding patterns can cause relief or concern. For example, some women worry that not bleeding while using the pill or another hormonal method causes unshed blood to build up inside the uterus. This is not true. Methods with combined estrogen and a progestin reduce the uterine lining and progestin-only methods prevent the lining of the uterus from building up, so there is nothing to shed. Another concern is spotting between periods or irregular bleeding. Irregular bleeding occurs most frequently in the beginning of method use, when the uterine lining has not completely thinned. This is not harmful, but it can be very annoying.