The cervical cap is a small, deep latex cup with a firm but flexible rim around the open end. It is 1 1/4 to 1 1/2 inches long and looks like a large rubber thimble. It fits snugly over the cervix and the os, the tiny opening to the cervix (Figure 5.1).
The cervical cap is similar to a diaphragm in that it does not cause any hormonal or chemical changes in the body. It has almost no side effects and does not interrupt lovemaking. When used for every single act of intercourse, the cap plus spermicide offers very good protection against pregnancy and some sexually transmitted
FIGURE 5.1 The Prentif Cervical Cap
IN A NUTSHELL
The cervical cap is a small, deep rubber cap that fits tightly over the cervix to prevent sperm from entering. It is used with a spermicide. You push the cap up your vagina and over the cervix anytime before you have sex. It must be left in place for at least 6 hours afterward, but you can wear it for as long as 48 hours.
A cervical cap protects you against pregnancy and some STDs. It does not protect against AIDS and the other STDs that are caused by viruses.
Cervical caps come in four sizes. Your clinic nurse or doctor will examine you to see if you can use the cap. With a prescription for the correct size you can buy a cap from the clinic. You also can buy the spermicide you will need at a pharmacy or the clinic.
diseases. It has not been shown to protect against AIDS and other virus-caused STDs.
Although the cervical cap functions like a diaphragm, it has a different shape, fits differently, and is used with less spermicide. It is held in place by suction, by its close fit on the cervix, and by the slight pressure of the surrounding vaginal wall.
Like the diaphragm, a cap requires a physical examination, including a Pap smear, and a fitting session. The standard fitting procedure also includes a follow-up Pap smear after the cap has been used for 3 months. A cervical cap usually needs to be replaced every 12 to 18 months.
A cervical cap has an advantage over the diaphragm because you can insert the cap many hours before having sex and, afterward, you can leave it in place longer.
The main disadvantage is that the only type of cervical cap avail-
able in the United States at this time (the Prentif cap) is made in just four sizes. Because anatomy varies, about 20 percent of women cannot get a good fit with the Prentif.
If you often try different positions while having intercourse, you may find that in some positions the cervical cap can be dislodged. This depends largely on the anatomy of your cervix, the fit of the cap, and the respective sizes of the vagina and penis.
The cervical cap has been used in Europe since the 19th century, but it was not approved for general use in the United States until 1988. It is still not well known here, and many physicians are not familiar with this method. Women's health centers and some health maintenance organizations are more likely to have the cap available.
In studies of the effectiveness of the cap in preventing pregnancy, failure rates ranged from 8 to 19 percent—or 8 to 19 pregnancies per 100 women during the first year of use. It also is considered a good, but not perfect, method of protection against STDs. Because it covers the cervix, it protects the upper reproductive tract against sperm and bacteria. However, it does not protect the vagina against bacteria, and whether it prevents virus-caused diseases, such as AIDS, is not proven.
As with other barrier contraceptives, the effectiveness of this method depends largely on how faithfully it is used. To protect yourself against pregnancy and disease, you must wear a cervical cap every time you have sex.
The cap cannot be used during menstruation because it does not permit any flow of secretions from the cervix. A male or female condom or a diaphragm are good birth control methods if you have intercourse during menstruation.
A disadvantage of the cap is that it can become dislodged during sex if it hasn't been put on correctly in the first place or if it does not fit securely because of the shape of the cervix. You can sometimes avoid having it come off by using a different position during intercourse. An experienced cap fitter may be able to tell you, based on your anatomy, what positions to avoid and what might be preferable.
You can improve the effectiveness of the cervical cap by adding a backup method during the first months you use the cap. Use a backup until you know from experience that you are placing the cap properly and it will not be dislodged. Another approach is to avoid intercourse or use condoms or extra spermicide during the most fertile days of your cycle. (For information on fertile days, see Chapter 14.)
The Prentif is the only cap available in the United States and not all women can wear it. Prentif caps come in four sizes and do not fit all women, largely because of ordinary variations in the anatomy of the individual cervix.
If the cervix has uneven sides, is exceptionally long or short, or is irregularly shaped, it usually is impossible to achieve the snug fit necessary for effective birth control. If the uterus is extremely anteflexed—bent so the cervix points back toward the spine--the cap could easily be dislodged.
A woman may not be able to use a cervical cap because she has a very long vagina and cannot reach her cervix to place a cap on it. An experienced cervical cap fitter can usually identify these problems.
The cervical cap seldom has negative health effects. There is a theoretical risk of toxic shock syndrome if you wear the cap for more than 72 hours, although no documented cases exist. To avoid the possibility of toxic shock, do not wear the cap for more than 48 hours or during menstruation. As we noted in Chapter 4, the symptoms of toxic shock syndrome include fever, muscle aches, diarrhea, and vomiting. The most distinctive symptom, however, is a sunburn-like rash on the palms of the hands and the soles of your feet. If you ever have had toxic shock you should not use the cervical cap.
If you suspect toxic shock, remove the cap immediately and, as soon as possible, call your doctor. If fewer than 6 hours have passed since you have had sex, insert an applicator of spermicide before you remove the cap.
If you ever have to remove the cap before 6 hours have elapsed, especially during your fertile period, you may want to discuss emergency contraception with your physician or family planning clinic. (See Chapter 16 for more information on emergency contraception.)
Unlike the diaphragm, the cervical cap exerts no pressure on the urinary tract, and it is seldom associated with an increase in urinary tract infections.
In a study of cervical cap use sponsored by the National Institutes of Health, 4 percent of the women who entered the study with normal Pap tests developed cervical tissue abnormalities during their first 3 months of using the cap. Researchers theorize that the layer of cells that lines the cervix may become more vulnerable to the human papilloma virus when a cervical cap is used regularly. Several of the many strains of human papilloma virus are associated with, or cause, cancer of the cervix. For this reason, the FDA has recommended that a Pap test be performed before a cap is fitted and again after three months of use. If either test shows any abnormal cells, another form of contraception should be adopted.
If a woman has developed an allergy to latex, she should not use the cap. Even without a latex allergy, there is always a slight risk that using the cap may irritate the cervix or the penis. The cause may be a sensitivity to the perfumes used in certain brands of spermicides or to nonoxynol-9, the active ingredient. To see if the irritation may be caused by the spermicide, switch to a different, unperfumed product or one with a lower percentage of nonoxynol-9 and apply it without the cap. If the irritation clears up after a number of days, use the new spermicide instead. If you think you may be allergic to latex, you should discuss this with the practitioner who fitted you with the cap. Since the latex Prentif is the only cervical cap available at this time, you may have to use another method.
Sometimes irritation is caused simply by leaving the cap on too long. The cap can be worn up to 48 hours after sex, and it must be left in place for at least 6 hours after intercourse. An irritation may subside if you use the cap for just that minimum length of time.
It is important not to tolerate a badly irritated cervix or vagina. The tiny cracks in the sore tissues may provide an opening for infection. If the irritation does not clear up in a short time, talk to your health care provider about it. In the meanwhile, your best protec tion is the nonlatex, polyurethane male condom sold under the name Avanti (see Chapter 2), or the polyurethane Reality female condom (see Chapter 3).
A new type of cervical cap made of silicone rubber is currently being tested for its effectiveness and safety in actual use. This form of rubber does not irritate and is soft, durable, easy to clean, and can be sterilized. It also is not easily damaged by heat, body fluids, or oil-based products. Called the Femcap, it is expected to become available sometime in late 1998.
If you live in a large city or town, the best way to find a source of cervical caps is to check the telephone yellow pages under clinics, health services, or women's health services. Although a woman's health center is more likely than a physician to be able to fit a cervical cap, you certainly should tell your gynecologist if you are interested in this form of birth control. Some health maintenance organizations (HMOs) also are now offering this method.
If you are under age 18 and wonder if the clinic or physician will tell your parents about your visit, you may find it helpful to ask some of the privacy questions listed on page 234 in Chapter 18.
The Prentif is a deep cap, almost 1 1/2 inches long. It is made of latex with a sturdy rim. On the inside of the rim is a groove that enhances the cap's ability to cling to the cervix. The Prentif comes in four sizes, with inside diameters of 22, 25, 28, and 31 millimeters.
Some days of the month are better than others for being fitted for a cervical cap. The best time is midcycle, between days 10 and 18. (Day 1 of the cycle is the first day of menstruation.) First, your health care provider will take your medical history, do a thorough pelvic examination, and perform a Pap test. The purpose of this is to discover any medical or anatomical problem involving the cervix, such as an irregular shape, that might make it impossible for a cap to achieve a good seal. If you have had a pelvic exam and Pap test within the preceding 3 months, you should not have to repeat this, the most expensive part of the exam, if you can get a note or a copy of the test results from the practitioner who performed the exam.
A cap cannot be fitted during menstruation, or when there is a vaginal or cervical infection. Nor can it be fitted during the weeks after childbirth or abortion or any procedure that involves the cervix, such as a dilatation and curettage (D&C). During the physical exam, the practitioner will assess whether the anatomy of your cervix makes you a good candidate for a cap and what size you are most likely to need. She will use sample caps to find the best fit.
To achieve a good fit, the inner diameter of the cap must be only a millimeter or two larger than the cervix. When the cap is in place, there should be no space between the rim and the cervix, and the cap should be deep enough that its top does not rest right on the opening of the cervix.
Because differences in anatomy affect the way the cap fits, it is a good idea to ask your practitioner just how well it covers your cervix. If the fit involves any unusual features, you want to be aware of them so you know when your cap is in the right place. For instance, if you have a long cervix, a cap might not completely cover it.
If you have any questions about cap placement or the security of its seal, or if the cap is uncomfortable, arrange for a fitting check after you have put it on at home.
Some women find inserting and removing the cervical cap a bit more difficult than using a diaphragm. Other women find that the cap requires less effort because it is smaller and easier to move through the vagina. With practice at home, most are able to slide it into place easily (Figure 5.2). Take all the time you need at your doctor's office or clinic until you feel sure that you are putting the cap in and taking it out with ease. In addition, sitting in on a cervical
Using one linger
Using one linger
FIGURE 5.2 Placing Cap on Cervix
Using two finyers
Using two finyers
FIGURE 5.2 Placing Cap on Cervix cap self-help group—if one is available—helps to ensure that you receive an adequate fit and are satisfied with this birth control method. Practitioners who fit caps are good sources for finding such a group.
• Before inserting the cap, locate your cervix with your fingers. Because its position changes throughout your menstrual cycle, knowing its current position makes it easier to put the cap in place.
• To make sure it is comfortable, practice inserting the cap several times and wear it for 8 hours before you actually use it for intercourse.
• To test its fit, remove the cap after 20 minutes and see if you can feel a raised ring around your cervix. If you can, your cap has a good, snug fit. If there is no ring, the cap may be too loose and you should tell your clinician.
• Before inserting your cap, empty your bladder and wash your hands. Choose a comfortable position: squatting, lying down with your legs bent, sitting on the edge of a sturdy chair, standing with one foot propped on a chair or the edge of the bathtub, or sitting on the toilet. (If you drop the cap, pick it up and wash it with soap and warm water.) Experiment until you find a position that works for you.
• Fill one-third of the dome with a spermicide. Do not use more; too much spermicide can prevent a good seal and may make it easier for the cap to come off during intercourse. Do not put spermi-cide into the hollow groove in the inside of the rim—it needs to be empty to hold onto the cervix—but do put a dab in one spot on the outer rim to make it easier to slide the cap into the vagina. You improve your protection if you also add an applicator of spermicide to your vagina after you insert the cap.
• Like the condom and the diaphragm, the cervical cap is latex and so can be damaged by any oil-based substance. If you want to use a lubricant during sex, try K-Y Jelly, H-R Lubricating Jelly, Surgilube, or any other water-based product available in drugstores.
• Pinch the edges of the cap together between your thumb and first finger. With your other hand spread apart the vaginal lips. Push the cap gently up into the vagina and along its back wall, with the opening facing up and the dome down. When your thumb can no longer reach far enough, use one or two of your longest fingers to move the cap along to the cervix. Push the cap on over the end of the cervix. Although this can be done with one finger, it is easier if you place the index finger on one side of the cap and the middle finger on the other and push it on. Then use those fingers to press around the entire rim to make certain the cap is pushed on as far as it will go and is securely in place.
• If it is hard for you to reach your cervix on certain days, try a squatting position or else bear down with your abdominal muscles as if you were having a bowel movement. This pressure pushes your cervix lower into the vagina. As we mentioned earlier, the cervix moves higher and lower in the vagina, depending on the time of month. If you continue to have difficulty inserting the cap, remove it, wait until you are more relaxed, and try again. You may want to try another position and check where your cervix is again.
Checking the Placement
When the cap is in place, use your longest finger to make sure the cap is positioned completely over the cervix (Figure 5.3). Experi-
enced fitters recommend checking at the back of the cap, where the cervix is easier to feel and recognize. If the cap is on properly, it should completely cover the cervix, including its sides—to where they meet the vaginal walls. The cap should not really touch the tip of the cervix. Its top or dome should not feel tight but should "dimple in" when you touch it. You should not be able to knock the cap loose. A well-fitting cap is difficult to remove.
If the cap is not correctly positioned, either straighten it with your fingers or remove it and reinsert it. Checking its position on the cervix is important because a cap can stick to the vaginal wall instead of sliding up to and on the cervix.
Positioning the cap sounds much more difficult and complex than it actually is. All barrier contraceptives take some practice at the beginning but using them soon becomes quick and almost automatic.
Insert the cap at least 20 to 30 minutes before sex so that a good seal can develop. If you have been wearing the cap for several hours before you have intercourse, make sure it is securely in place before you begin lovemaking. You can do this in the bathroom or in bed.
CERVICAL CAP POINTERS
For the first few weeks or months that you use the cap—until you have enough experience with it to feel certain you are using it correctly and know it will not be dislodged—back it up with extra spermicide or a male condom. If the cap does become loose during sex, try different positions to find one that does not dislodge it. Use a backup contraceptive method while you are experimenting. If the cap still comes loose, return to your health care provider to try to resolve the problem.
It is not a good idea to wear the cap during those days of your period when blood flow is heavy. If blood spills over the rim, it breaks the seal between the cap and the cervix. Since it is sometimes possible to become pregnant during menstruation, you or your partner should use another form of birth control at this time.
Displacement of the cap occurs most often when the penis is able to reach the cervix. The angle of the cervix or the angle of penetration may cause the penis to bump the side of the cap rather than its top, pushing it out of place. Soon after intercourse, check to see whether the cap is still firmly on the cervix. If it is loose, push it back on and immediately add an applicator of spermicide well back into the vagina. If it is completely dislodged, remove it, put some spermi-cide in the cap if necessary, and replace it. Then add the extra spermicide. If the cap becomes dislodged frequently, even when you use a different position for sex, see the health care provider who fitted you. You may have to consider using another birth control method.
If the cap is dislodged during intercourse, you may want to discuss emergency contraception with your health care provider. To be most effective, emergency contraception should be started within 72 hours after intercourse (see Chapter 16).
If the Cap Becomes Dislodged
To put spermicide into the vagina, remove the top of the tube and attach the applicator in its place. (Applicators are included in "starter" packages of spermicide.) Squeeze the tube until the applicator is full, disconnect it, and insert the applicator up into your vaginal canal, much like a tampon. Gently push the plunger as far as it can go. Remove the applicator without tugging on the plunger, which could pull up some of the spermicide.
If you have intercourse later while the cap is still in place, leave it on. You may add more spermicide to your vagina if you wish.
After intercourse, leave the cap in place for at least 6 hours. If it is convenient, you can leave it in for as long as a day or two. Most practitioners recommend that the cap not be worn more than 2 days at a time, largely because of the odor caused by exposing it to vaginal secretions. In addition, not enough is known about the long-term effects of blocking the flow of normal cervical secretions and the risk of toxic shock syndrome. However, some women can wear a cap almost constantly without a problem. They remove it every other day or once a day for a few hours to wash it and to allow cervical secretions to flow freely.
Do not douche while wearing a cervical cap, because you could dilute the spermicide or force sperm into the cap. The douching solution also might make holes in the rubber.
To remove the cap, it is necessary to break the force of the seal. After you have worn the cap for some hours, the cervix swells slightly, creating an even tighter fit. With experience you will learn how much effort you need to loosen it.
After finding a good position, hook a finger over the back rim of the cap and pull. Or push the dome forward or upward with your first finger while your middle finger hooks over the back rim and pulls down. If sometimes you cannot reach the cap, even when bearing down with your abdominal muscles, ask your practitioner for the diaphragm introducer (the Universal Introducer). It has a small hook on one end that is useful for removing cervical caps.
Whenever you remove it, wash the cap with a mild, unscented soap and warm water. Turn it inside out in order to clean the hollow groove inside the rim. Use a strong flow of warm water or a soft toothbrush on the groove. Do not boil the cap or use strong cleaners.
Dry the cap and, if you are not going to use it soon, dust it lightly with cornstarch to help protect the rubber from contact with anything greasy. Do not use talcum or baby powders, because they can cause rubber to deteriorate. Such scented powders also can irritate your vagina.
Do not rest your cervical cap on newspaper, because it often contains materials that can perforate rubber. Keep the cap away from extreme heat and sunlight because these, too, cause rubber to deteriorate. Store the cap in its container.
If an unpleasant odor develops when you wear your cervical cap for long periods, you may need to remove it more often, at least once a day, for cleaning. You often can neutralize odor by soaking the cap in lemon juice, mouthwash, or a mild solution of one teaspoon of white or cider vinegar to a quart of water. Soak it for 20 minutes. The vinegar solution will turn the cap brown, but this will not affect its reliability. Rinse it thoroughly in warm water and dry it. Odors also can be removed by adding a drop of liquid chlorophyll to the cap before using it or by soaking it in a cup of water mixed with a drop of chlorophyll. Chlorophyll is available from pharmacies and from some natural food stores. Do not soak the cap for more than 20 to 30 minutes.
If you have a vaginal infection, wash and sterilize the cap in rubbing alcohol (available from drugstores) for l5 minutes each time you remove it. It is also a good idea to have your partner wear a condom for his protection until the infection is cleared up.
The regular use of alcohol and acidic solutions such as vinegar and water or lemon juice hasten the deterioration of rubber. At the first sign of any cracking, hardness, stickiness, or an odor you cannot get rid of, get a new cap. Generally speaking, caps should be replaced every year. How long each one lasts depends on how often you use it, the effect of your body on the latex, and how well you take care of it.
Every time you use your cap, examine it for holes, cracks, and signs of wear. Hold it up to the light or check for leaks by filling it with water. Have it checked when you have your annual pelvic exam and Pap smear. Your health care provider may observe changes in the cap you have not noticed. The rubber may be slightly deteriorating or the shape may have altered so it no longer provides a tight seal.
The fit of a cap should also be tested after childbirth, a miscarriage, or an abortion. After a birth, the cervix takes about 6 weeks to return to normal size. The fit should also be checked after any surgery on the cervix, including laser, electrocautery, or cryotherapy, and after any gynecological procedure in which the cervix is dilated, such as a D&C. If you are breastfeeding when you are fitted with your cap, have the size checked when you are once again menstruat-ing—your cervix may have become larger. And if you were fitted while you were on oral contraceptives, have the fit tested after you have your first spontaneous period off the Pill.
States with large populations and large cities are likely to have numerous health professionals trained to fit cervical caps. In states with fewer people, the number of practitioners fitting caps is still relatively small, although it continues to grow. To find a provider near you, contact Cervical Cap Ltd., 430 Monterey Avenue, Suite 1B, Los Gatos, CA 95030, 408-395-2100, for an updated list for your area.
A cervical cap, the fitting procedure, and a pelvic examination and Pap smear will range in cost from $100 to $200. If you have a choice of providers, it is wise to shop around because prices can vary even within the same city.
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