The Female Condom

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Currently, there is only one version of a female condom on the market: the Reality Female Condom. It is a soft, loose-fitting tube or long pouch that is made of a very thin, strong, transparent polyurethane, approximately 3 inches in diameter and 6 to 7 inches long. It looks a bit like a miniature wind sock (Figure 3.1). It is designed to line the inner contours of the vagina and protect a woman against sperm and the bacteria and viruses that cause disease, including AIDS. The female condom has a flexible, narrow ring at both ends. The slightly smaller ring inside the closed end helps to place that end over the cervix and to hold it there. The ring at the open end remains outside the vagina and serves as the entry for the penis. The pouch is lubricated both inside and out. Like the male condom, it is meant for one-time use.

The female condom not only protects the vagina and cervix from sperm and microbes, it is sized so that the open end also covers a woman's external genitals and the base of her partner's penis, offering both of them excellent protection against disease.

Because it is made of polyurethane, the female condom has the advantage of being stronger than latex and less likely to tear or develop tiny holes. It will not aggravate a latex allergy. It is not

IN A NUTSHELL

THE FEMALE CONDOM

The female condom is larger and looser than the male condom. The closed end fits over the cervix, inside the vagina. The open end hangs slightly outside and protects the lips of the vagina. Because it is made of polyurethane, it becomes very soft and flexible when it is in place. It is very effective in protecting both partners against pregnancy and diseases, including AIDS.

Like a male condom, the female condom can be bought by anyone. You do not need a prescription. It is sold in drugstores under the name Reality Female Condom. The cost is higher than a male condom.

You will want to practice putting it in place before you use it. It does not interrupt lovemaking because you can insert it ahead of time.

Although the female condom looks a little strange, many women and men find they like it. A man likes it because it's more comfortable than a male condom and he doesn't have to pull out as soon as he has come (ejaculated). Women like it because it gives them control over their own safety.

affected by oil-based creams or lotions and is less vulnerable to deterioration caused by exposure to heat or lengthy storage. Like the Avanti condom, it transfers body heat easily, which means it quickly feels warm and soft and permits more sensation.

When it was tested in actual use, about one-third of the men said they preferred the female condom over the male condom because it was roomier. Some men noted that it felt more natural to them because the penis could move freely in and out. They liked the fact that they did not have to interrupt their love-making to put on a condom. They also could linger as long as they wanted after ejaculation because, unlike using a male condom, they did not have to withdraw while their penis was still erect. You can put the female condom in place up to 8 hours before intercourse and you do not need a spermicide for extra safety. The female condom should be removed before you stand up.

For many women, however, the major advantage of the female condom is that it gives them control over their own protection against STDs, instead of trying to convince their partners to protect them by using a condom.

The female condom can be

WHO LIKES THE FEMALE CONDOM?

• Women who are concerned about STD transmission and cannot get a man to use a condom.

• Women who prefer to have control over risks in their lives.

• Women who have sexual relationships with more than one partner or have one monogamous relationship after another.

• Women who use oral contraceptives, Depo-Provera, Norplant, or an IUD but also want protection against STDs.

• Women interested in trying different barrier methods.

Outer Ring

Inner Ring

Inner Ring

Outer Ring

Internal Condom

y Female condom in place

FIGURE 3.1 The Female Condom y Female condom in place

FIGURE 3.1 The Female Condom bought without a prescription and at most drugstores. The package, while not as compact as packets of men's condoms, is small enough to tuck into a purse or pocket.

The female condom does not require a physical examination and a fitting like a diaphragm because it does not have to provide a snug cover for the cervix. It is protective because all the semen is trapped in its long pouch. However, if you have never used a barrier contraceptive like the diaphragm you may want to seek the help of a health care provider at a women's health center or family planning clinic.

Women's health clinics that offer the female condom report that their clients "either love it or hate it." In studies of the Reality condom, the women who used it said that the biggest disadvantage was the sensation of having something outside the vagina; however, many of those who used this type of condom for a week or two said they soon became accustomed to this and barely noticed it. Some found that the part of the condom that lies outside the body tended to stimulate the clitoris, adding to their pleasure. Although many of their partners reported that they could feel the condom, they did not necessarily find it objectionable.

The Reality condom can be noisy if the lubricant inside is not spread evenly around the outer end or if there just is not enough lubricant. Furthermore, if lovemaking is lengthy, the lubrication may get used up and the polyurethane will become somewhat dry. The solution is to add two drops (or more as needed) of lubricant to the entrance of the condom or on the penis. Extra lubricant is supplied with each starter package of Reality condoms.

EFFECTIVENESS

Laboratory tests of the polyurethane used in the Reality condom (and in the Avanti male condom) have demonstrated that the AIDS and hepatitis B viruses are not able to penetrate the polyurethane. (Hepatitis B is the smallest virus known to cause an STD.)

A study of the contraceptive effectiveness of the female condom in actual use found that it is as good as other barrier methods—the male condom, the diaphragm, or the cervical cap—in protecting against pregnancy. The rate of accidental pregnancy during a 6-month period ranged from 2.6 percent (for women who used the condom correctly and for every single intercourse) to 12.4 percent (for typical, less-than-perfect use). To arrive at a 12-month failure rate, the FDA doubled the rates from the 6-month study: the failure rate for perfect users is now listed as 5 percent and, for typical users, as 21 percent.

The results of this clinical study of effectiveness have led researchers to suggest that the perfect use of this condom could also substantially reduce women's risk of acquiring HIV. They estimate that, among women who have intercourse twice a week with an infected man, the annual risk of acquiring the infection could be reduced by 90 percent.

HEALTH EFFECTS

Because it is made of polyurethane rather than latex, the Reality condom is a good choice for the numbers of women (or their partners) who are allergic to latex rubber. In addition, it does not require the use of a spermicide, so it is attractive to those who are irritated by the ingredients in today's spermicides.

Although polyurethane is not as likely as latex to irritate the vagina or the penis, there is always a slight possibility that such irritations might occur. Frequent use of polyurethane condoms may sensitize some individuals to the material although, so far, this complaint has been rare. The symptoms are itching and mild pain.

USING A FEMALE CONDOM

Female condoms are available chiefly from large drugstore chains, where they are usually stocked near the supply of male condoms. They also can be bought at many women's health clinics.

Because the female condom is so new and looks so different, even someone who has used a diaphragm or a tampon may be nervous about trying it. It helps to have a sense of humor when trying it and to practice with it a few times before actually having sex. Take your time and become at ease with this type of condom before actually using it for protection.

Inserting the Female Condom

Before you try to insert the condom, read the section on female anatomy in Chapter 1 and familiarize yourself with your vagina and the location of your pubic bone and cervix. You will be much more relaxed about using any barrier contraceptive—and about sex—if you are acquainted with your own body.

Although the directions for inserting this condom are lengthy because they cover every detail, after a little practice you will find that insertion is quite simple and quick (Figure 3.2). If you have difficulty with it, take a break, relax, and re-read the directions given here or those that come with the package before you try again. Being relaxed and willing to experiment will make the process much easier.

• The closed end of the female condom is designed to fit over the cervix, and the open end stays on the outside of your body.

• The condom can be inserted anytime up to 8 hours before having sex.

• If you are not familiar with your vagina, check it out before you try inserting the condom. Use your middle finger to find your cervix at the upper end. It feels somewhat like the end of your nose, and it is about 3 inches from the vagina's opening. The vagina itself is not very long.

• To be sure the lubrication is spread evenly on the inside of the long pouch, from bottom to top, rub the outside of the condom gently. The lubricant is designed to make the inside of the condom feel similar to the naturally lubricated vagina. If the penis does not slip in and out easily during use, you can add more lubricant from the extra supply in the package.

• Before you try inserting the female condom, find a comfortable position. You can sit on the edge of a chair with your knees apart, or sit on the toilet, or lie down.

• Be sure the inside ring is down at the closed end of the tube. The inside ring is a bit smaller and thicker than the outside ring.

• To make it easier to insert the condom, add a drop or two of extra lubricant to the outside of the closed end of the pouch. Too much lubricant, however, may make it hard to grasp the ring firmly.

• Hold the pouch by the inside ring, with the open end hanging down. Squeeze the sides of the inner ring together to make it narrow

Anatomy Penis Inserted Vagina

enough to go into your vagina. It may be easier if you squeeze it between your thumb and middle finger, with your index finger on top of the ring to help hold it steady. Be careful not to tear the condom with your fingernails or rings.

• Use your other hand to spread the outer and inner lips of your vagina and then insert the squeezed inner ring. If it slips from your fingers, let it go and start over. The condom is well lubricated, which can make it a little difficult to manage. If your vagina feels a little dry, however, you may need to add some more lubricant to the condom or to the entrance of your vagina.

• Push the inner ring and the pouch all the way up into your vagina as far as it will go. (Vaginas are about 2 1/2 to 4 inches long.) The easiest guide for doing this is to follow the lower or back wall of the vagina with the folded ring until it stops. This will help the leading edge of the ring to go under and past the cervix and touch the back wall of your vagina where it joins the cervix. The end of the folded ring closest to the vaginal opening should then be just past your pubic bone. You can feel your pubic bone—it is barely a finger's length inside the vagina. Push the ring up behind the pubic bone, which will help hold it in place. (See Chapter 1 for more information about your anatomy.)

• When the condom is in place, it covers your cervix and you should be able to feel the cervix through it. If the condom is not comfortable, it may not be correctly positioned. Remove it (twist the outer ring and gently pull) and try again. It takes a little practice to get it in place behind the pubic bone and over the cervix. Aim the leading edge a little lower so it does not hit the cervix instead of the back wall of the vagina. When you think you have the condom in place, you can check it with your finger to make sure it is over the cervix.

• About 1 inch of the open end of the condom will remain outside your vagina. While this may look unusual, it is this extra material that protects your genital area and the upper part of your partner's penis.

• Use a fresh condom for each intercourse, because the used one may have been torn or contaminated with body fluids. Do not use a

Reality and a male condom at the same time. They will stick to each other and will not stay in place.

• When you are ready to have sex, make sure the outside ring is lying flat against the outer lips of your vagina. As the penis begins to enter, guide it into the ring. If this entry is not easy, ask your partner to withdraw for a second while you add more lubricant either to his penis or to the inside of the condom. If you do not have Reality lubricant, you can use any gel or oil—polyurethane condoms are not damaged by oils.

• It is normal for the female condom to move around during sex and for the outer ring to move from side to side. It is even okay if it rides up on the penis—this does not reduce your protection because the penis is still covered and the semen stays inside the pouch.

• If you begin to feel the outer ring being pushed into the vagina or if the penis starts to enter underneath or next to the condom instead of into it, stop. You or your partner may need to add extra lubrication to the opening of the pouch and make sure the outer ring is lying flat over the lips of the vagina—this will make it easier for the penis to slide into the condom. The Reality should not bunch up if there is enough lubricant in it. It helps if you make sure the outer ring is lying flat while you guide the penis into it.

Removing the Female Condom

To remove the Reality after sex (before you stand up), squeeze the outer ring and twist it to keep any sperm from spilling. Pull gently to remove the condom, wrap it in tissues, and drop it in a trash can. Do not flush it down the toilet and do not reuse it.

COST

The only female condom on the market today is the Reality. Costs range from $7.00 to $8.99 for a package of three, and a package of six is $13.00 or more. Large drugstore chains tend to have the lowest prices.

The Diaphragm

The diaphragm is a shallow rubber cap with a rim made of a fine, flexible spring (Figure 4.1). It fits snugly and comfortably across the upper vagina, covering the entire cervix, thus preventing sperm from getting into the uterus and fallopian tubes to fertilize an egg. It is used with a spermicidal (sperm-killing) jelly or gel.

The diaphragm is a popular method of birth control because it does not cause any hormonal or chemical changes in the body. It has almost no side effects and does not have to interrupt lovemaking. Few men are bothered by the presence of a diaphragm, if they even notice it. It can be used during menstruation.

When used consistently and carefully, a diaphragm plus spermi-cide offers quite good protection against pregnancy and those sexu-

FIGURE 4.1 Diaphragm

IN A NUTSHELL

THE DIAPHRAGM

The diaphragm is a method of birth control used by a woman. It looks like a rubber cap with a flexible rim. It is always used with a spermi-cide (sperm-killing) gel. It is designed to fit over the cervix (at the upper end of the vagina) to prevent sperm from getting into it. You put it in place before you have sex. It prevents pregnancy and protects against some STDs, but not all. It has not been shown to protect against AIDS.

Because diaphragms must fit well to be effective, they come in several sizes. A diaphragm should fit so it stays in place but you do not feel it. A nurse or doctor must examine you and write a prescription for the correct size. With the prescription, you can buy a diaphragm at a pharmacy or a clinic. You do not need a prescription for a spermicide, which you can buy at the clinic, pharmacy, or supermarket.

You can put in the diaphragm up to 6 hours before you have sex and you must leave it in for at least 6 hours afterward.

ally transmitted diseases caused by bacteria. The risk of pelvic inflammatory disease (PID) is reduced substantially by the use of a diaphragm. Whether it protects against AIDS and other virus-caused diseases has not yet been proved.

A diaphragm needs to be fitted by a doctor or other health care provider and generally can be used for several years or longer.

The diaphragm is a particularly good method if you do not have sex frequently or if you know in advance when you will have intercourse. If you own a diaphragm but are now on the Pill, the diaphragm can provide good emergency protection if you run out of pills or are vulnerable to pregnancy because you forgot to take two or more pills. Some couples like the idea of using a contraceptive only when they believe that the woman is fertile, and they use a diaphragm, cervical cap, or condom during that time.

To be most effective, the diaphragm is used with a spermicide. It must be inserted before intercourse and must remain in place for 6 hours afterward. It should be kept handy even when you do not expect to have sex. You also need to keep a supply of spermicide on hand.

ARE YOU A GOOD CANDIDATE FOR A DIAPHRAGM?

If touching your genitals is distasteful to you, you may prefer another method of birth control.

If spontaneous, uninterrupted sex is important to you or your partner, and stopping at any point to insert the diaphragm is a nuisance that would discourage your use of it, you may want to consider another method of birth control. (To overcome this drawback, however, you can wear the diaphragm every time you are with your partner, or put it in when you get ready for bed.)

Using this contraceptive effectively also requires a certain amount of planning ahead so that you have both the diaphragm and a supply of spermicide handy. To protect it from damage, the diaphragm should be carried in its case, which is roughly 5 x 8 inches and fits into a large purse. The case often has room for a tube of spermicide. To be safe, you need to take it with you whenever you might need it. If this is not easy, another method may be a better choice.

On the other hand, the diaphragm is a good method of birth control for the woman who should not use hormonal methods because of health reasons—such as a heart problem or smoking habit.

It has a few disadvantages. If you often try different positions when having sex, you may find that the diaphragm can be dislodged when the woman is on top. This does not happen often or to everyone, but it is possible. It may depend on the woman's anatomy or the fit of the device.

During oral sex, some spermicides can leave an unpleasant taste, although this can be eliminated by wiping off your genital area after you insert the diaphragm. Both flavored and unflavored spermicidal products are available.

A spermicide is recommended because the diaphragm itself may not be completely effective in stopping sperm from entering the cervix. During intercourse, the vagina can flex and change in shape. As a result, a diaphragm cannot provide a perfect seal, and some sperm may slip past it. To protect against this possibility, a spermicidal jelly or cream is used with the diaphragm each time. One of the diaphragm's functions is to hold spermicide close to the cervical

opening to destroy any sperm that get past the rim. Approximately two teaspoons of a spermicide are put in the cup of the diaphragm before it is inserted. (For more information on spermicides, see Chapter 6.)

EFFECTIVENESS

Like condoms and cervical caps, the diaphragm's effectiveness depends directly on how carefully and consistently it is used. Rates of failure vary widely, ranging from 5 to 21 percent during the first 12 months of use. Women who do not use the diaphragm every single time they have sex have the highest failure rate. Women who use it carefully every time they have sex experience the lowest rate of failure. Leaving the diaphragm at home is one of the most common reasons for failure.

Age and frequency of intercourse also affect the chance of failure. Diaphragm users who are under age 25 or who have sex frequently run a greater risk of becoming pregnant. Men and women in their teens and twenties are usually extremely fertile, which increases their risk of pregnancy. And, when intercourse is frequent, there are more chances for contraceptive failure, unless the couple is very disciplined about using this or any barrier method.

To prevent pregnancy and disease, it is necessary to use the diaphragm every time you have sex, even during menstruation and the so-called "safe" days shortly before or after menstruation. For greatest protection, a condom can be used in addition during the woman's most fertile days. (For information on determining your fertile and nonfertile days, see Chapter 14.)

HEALTH EFFECTS

As a rule, the diaphragm produces no serious, negative effects on the body, nor can it be lost in the vagina or in the upper reproductive tract.

Beneficial Effects

A diaphragm used with a spermicide is an effective barrier against the organisms that cause such STDs as gonorrhea, trichomoniasis, and chlamydia. In addition, cancer of the cervix has been found to be much less common in women who consistently used a diaphragm during intercourse for at least 5 years.

Urinary Tract Infections

Some women who wear diaphragms have a slightly increased risk of repeated urinary tract infections. The pressure of the rim on the urethra and bladder may be a factor in this. A diaphragm in a smaller size or with a different type of rim may exert less pressure and eliminate this possibility. As a precaution against infection, the diaphragm should be washed thoroughly with soap and water after each use, and the user should wash her hands before taking it from the case.

Toxic Shock Syndrome

Symptoms of this rare syndrome include fever, diarrhea, vomiting, muscle aches, and a sunburn-like rash, particularly on the palms of your hands and the soles of your feet. If these should occur, call your doctor. Although toxic shock is unusual, it is so serious the possibility should not be overlooked.

Allergic Reactions

In some instances, a diaphragm user or her partner is allergic to the latex or the spermicide. Women experience this problem more often than men, developing an irritation in the vagina. The cause may be a sensitivity to the perfumes used in certain brands of spermicides or to nonoxynol-9, the active ingredient. Using an un-scented spermicide, or one that contains less nonoxynol-9, may solve the problem. To discover if the allergy is from the spermicide, insert some by itself into the vagina without the diaphragm. Either have no sex during this time or do this during the nonfertile days of your cycle. If you can do this for several days without irritation, the spermicide is probably not the cause.

Instead of an allergy, sometimes vaginal soreness is just the result of irritation from the spermicide. Talk to your health care provider about this problem and about using another, nonirritating form of contraception. Condoms may provide a solution, and the cervical cap is another choice. Since it requires very little spermicide, the cap can sometimes be a good method for women who tend to be irritated by spermicides (see Chapter 5).

If the spermicide is not the source of the irritation, latex is the likely suspect. Since all diaphragms today are made of latex, if you want to continue with a barrier method, the only nonlatex choices are the new polyurethane or Tactylon male condoms (Chapter 2) or the female condom (Chapter 3).

USING THE DIAPHRAGM

Diaphragms are available from women's health centers and Planned Parenthood clinics, from physicians, particularly family practitioners and gynecologists, and from nurse-midwives, nurse-practitioners, and other health professionals specializing in family planning. Spermicides are also available from these sources or from the feminine hygiene or family planning sections in drugstores.

Types of Diaphragms

Diaphragms are available in sizes measured in millimeters, ranging from 50 to 95 millimeters (about 2 to 4 inches) in diameter. The size you need depends on the size of your upper vagina, which is related to your body size and weight, as well as whether you experienced a vaginal childbirth. Diaphragms are available with different types of rims that make it possible to fit many different bodies.

The diaphragm with a flat spring rim exerts a very gentle pressure. It is often the best choice for the woman whose vaginal muscles are very firm because she has not yet had a baby. A coil spring rim is stronger and is designed for the vagina with a more relaxed muscle wall. A diaphragm with an arcing spring rim bends in only two places, which some women find easier to handle.

Both the arcing spring and coil spring types are available with an extra "wide seal" inner rim of soft latex. This is intended to create a better seal with the vaginal wall and to be more effective in holding the spermicide around the cervix.

Being Fitted

Because the diaphragm must fit very well, it is necessary to have an internal pelvic examination by a physician or other health care provider. The examination rules out any problem that would prevent you from using a diaphragm successfully, such as an abnormality of the vagina, cervix, or uterus. This is also a good time to ask to be examined for infections of the lower reproductive tract. Many infections have no symptoms and without a lab test they could remain undiscovered. They should be treated before they cause complications.

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.

During the exam, the practitioner will assess which type and size of diaphragm will suit your body best. This usually is done with fitting rings or sample diaphragms, and several may have to be tried to find the size that is comfortable and secure in the vagina. The ideal is the largest model that is snug without discomfort. A diaphragm is a good fit if it touches the walls of the vagina with just enough room to insert a fingertip beneath the pubic bone.

If you are not at ease with the idea of inserting and removing a diaphragm by hand, some types can be used with a plastic inserter. Discuss this possibility with your practitioner.

Part of the fitting procedure must include a lesson on how to insert and remove the diaphragm. You should be given plenty of opportunity to practice while you are still in the examining room. If the rim is too stiff to be squeezed together by one hand, a model with a less firm spring may be preferable. Although more practice with the diaphragm will make it easier to use, you should feel fairly confident about inserting it before you leave the clinic.

If you wish, it usually is possible to take the diaphragm home to practice inserting it and then, while wearing it, go back to your practitioner to make sure it is in the right place. This is not possible if you are simply given a prescription for buying the diaphragm at a drugstore.

You want to be able to put it in and take it out correctly and easily before you actually use the diaphragm. If it is a good fit, you should not be able to feel it. It may be too large if you feel the need to urinate shortly after you put it in or if you have a sense of pressure on your abdomen. When abdominal pain or cramping or vaginal pressure accompany the presence of the diaphragm, its position and size should be checked. Do not accept one that causes you any discomfort when it is correctly placed.

How to Insert the Diaphragm

• Before putting in the diaphragm, wash your hands. If you are not familiar with the anatomy of your vagina and cervix, you will find it easier to use this method if you know where your cervix and pubic bone are (see Chapter 1) and what they feel like. There is no need to be embarrassed—after all, this is an important part of your body and you should know about it.

• Fill the diaphragm almost two-thirds full of a spermicide (a couple of inches or about 2 or 3 teaspoons). How much you need depends on its size: a larger one will require more spermicide. Spread it around and up on the inside of the rim. For extra protection, some women smear a bit of spermicide on the outside of the diaphragm or put a dab on one spot of the outer rim, which is less messy. Avoid making the outside of the rim too slippery—you may find the diaphragm flying out of your hand!

• You can insert the diaphragm while sitting on the toilet, or lying down with your legs bent, or in a squatting position—whatever works for you (Figure 4.2). If you sit on the toilet, take care that the rim of the diaphragm is not slippery from spermicide because it may slip from your hands.

Penis Put With Vagina
FIGURE 4.2 How to Insert a Diaphragm

• If you ever drop your diaphragm, wash it well with soap and water, add spermicide, and start over.

• With the open side of the cup facing upward, firmly squeeze the sides of the rim together between your thumb and fingers to fold it for insertion. If the spermicide has made the rim too slippery to grasp, wipe it from the outer edge only, not from the inside. A little spermicide in one spot on the leading edge, however, does help it slide more easily into the vagina.

• While you hold the folded diaphragm in one hand, spread apart the lips of the vagina with the other hand and then ease the diaphragm up into the vaginal canal as far back as it will go—about two or three inches. The leading edge of the rim should slip under and behind the cervix and touch the vaginal wall. Then gently but firmly push the other edge up behind the pubic bone. When it is in the correct position, the diaphragm should cover the cervix, feel comfortable, and stay in place.

• Use your longest finger to make sure the rim of the diaphragm closest to the vaginal opening is tucked up behind the pubic bone and that the cervix is covered by the soft rubber dome. Your cervix is at the upper end of your vagina—it feels like the tip of your nose— and you should be able to feel it through the latex. Touching it through the diaphragm also makes sure the spermicide is in contact with the cervical opening, protecting it from sperm.

• If you are aware of your diaphragm when you are wearing it, it is probably not correctly placed. Take it out and try again. Try sitting differently when you insert it. Also make more of an effort to keep the leading edge of the diaphragm low so it goes under the cervix. Remember that using any barrier method is awkward at first and it takes a little practice before the diaphragm becomes easy to insert.

The Spermicide

Spermicides lose their effectiveness in the body as time passes. If you inserted the diaphragm more than two hours before actually having sex, squeeze another application directly into your vagina.

NOTE: Do not take out the diaphragm when you add more spermicide.

To use the plastic applicator that comes with the spermicide, remove the cap from the tube and attach the applicator in its place. Squeeze the tube so the jelly, gel, or cream pushes into the applicator and fills it. Disconnect the applicator and insert it well into your vagina, just as you would a tampon, and then gently push the plunger in as far as it will go. When you remove the applicator, do not tug on the plunger because that might pull some of the cream back into it. Contraceptive foams, available in most drugstores, can be used with diaphragms instead of a cream or gel (for more information on spermicide products, see Chapter 6). You can apply the spermicide in the bathroom or while still in bed. It takes only a moment.

As we noted in the chapter on condoms (Chapter 2), when you use a latex device, it is vital not to use petroleum jelly or any other oil-based ointment or cream instead of a spermicide. For one thing, these products do not kill sperm. For another, any product with oil in it weakens latex and causes it to develop tiny holes that allow sperm, viruses, and bacteria to pass through. If you want to use a lubricant during intercourse, use your spermicide or a water-based vaginal lubricant such as K-Y Jelly, Ortho-Gynol, or Koromex Gel. When you buy a lubricant, read the label carefully to make sure it is safe to use with latex.

Afterward

After sex is over, leave the diaphragm in place for at least 6 hours. It takes that long for the spermicide to kill all the sperm. Although in some cases the diaphragm can be dislodged if the vagina flexes a great deal during intercourse, you can safely take a bath, shower, swim, bicycle, and perform almost any kind of physical activity without it moving out of place. You also can have a bowel movement without dislodging it. Do not douche while wearing a diaphragm. Douching washes away protective spermicides and can force sperm up the cervix.

You can leave the diaphragm in place for longer than 8 hours, and many women prefer to do so. In fact, it is usually more convenient to wait until morning to remove it. But do not leave it in for more than 24 hours at a stretch. Leaving barriers in place for extended periods of time may be associated with increased risk of toxic shock syndrome.

Further Intercourse

Before having more sex, add an applicator of spermicide. If 8 or more hours have passed, and you expect to have intercourse again, you can remove and wash the diaphragm if you wish, add more spermicide, and reinsert it. Or you can just leave the diaphragm in place and add more spermicide.

Removing the Diaphragm

Before removing the diaphragm, again, wash your hands. Then find a comfortable position. Hook a finger under the part of the diaphragm that rests behind the pubic bone or at any other point

DIAPHRAGM POINTERS

• Do not forget to take your diaphragm with you when you go on vacation or away for the weekend. If you travel frequently, keep a second diaphragm and supply of spermicide in your travel kit.

• Always keep a tube of spermicide and applicator with your diaphragm in its case.

• If your diaphragm becomes dislodged during intercourse, immediately add more spermicide well into the vagina. Talk to your health care provider as soon as possible about emergency contraception (see Chapter 16).

• If you are not sure that you are inserting the diaphragm correctly, or if it does not feel comfortable, have the placement checked by the health care provider who fitted you. Meanwhile, have your partner use a condom for extra protection. (It is always a good idea to keep a supply of condoms on hand.)

toward the front of the vagina. Firmly pull forward and down. If it is a good fit, it may take a bit of effort to dislodge the diaphragm. Be careful not to poke a fingernail through it. Because a certain amount of sperm and contraceptive cream will come out of the vagina with the diaphragm, many women remove their diaphragms while sitting on the toilet. The use of a minipad or tampon will protect you against any leakage afterward.

CARE AND STORAGE

Simple care extends a diaphragm's life and effectiveness. After using it, wash it with soap and warm water, rinse, and pat it dry with a clean towel. (A diaphragm should not be put away while still wet.) Do not use antiseptics or strong cleansing solutions on a diaphragm, because they weaken the latex. To protect it further, before returning it to its case, dust the diaphragm with cornstarch—not talcum or any other perfumed powders; the perfumes can damage it. Store your diaphragm in its case and do not expose it to sunlight or extreme heat.

Examine your diaphragm every few weeks for holes, especially around the rim. Even the tiniest pinhole can admit hundreds of sperm. To make a check, hold it up to the light and look at it carefully. Or fill it with water to see if it leaks. The latex will gradually grow darker with time; this is all right, it does not affect its function. Replace the diaphragm when the rubber shows signs of deterioration, such as cracks or brittleness.

CHECKING YOUR DIAPHRAGM

Your diaphragm and its fit should be checked every 18 months or so. This can be done when you have your regular pelvic exam and Pap smear. The fit should also be checked in the following circumstances:

• if you have lost or gained more than 20 pounds;

• if you have had a child, a miscarriage, an abortion, or any type of surgery involving your reproductive organs;

• anytime you experience discomfort, pain, or recurring bladder infections after using the diaphragm; or

• anytime you suspect your diaphragm is not fitting properly or that you might not be inserting it correctly.

COST

The medical examination and a diaphragm fitting can cost from $75 to $150 or more, depending on where you live and who does it. Women's health centers, state or city family planning clinics, and Planned Parenthood clinics usually offer the lowest costs. The most expensive source may be your gynecologist. However, if you have been having regular pelvic examinations, your gynecologist, internist, family practitioner, or adolescent medicine specialist may do just the fitting procedure for less than the cost of an exam. The cost of the diaphragm may be included.

Prices of spermicidal gels, jellies, and creams begin at $8 and the tubes vary in the number of ounces they hold. An ounce of spermi-cide is equal to 6 teaspoons or 2 to 3 applications. A 3.8 ounce tube contains about 10 applications. Read the label to be sure the contents actually are a spermicidal—are intended to kill sperm. Some vaginal lubricants that do not contain nonoxynol-9 (the active sperm-killing ingredient) are sold in similar packages, although they usually are much cheaper. Contraceptive foams and gels often are available at reduced cost from Planned Parenthood and other family planning clinics.

If you need to replace your diaphragm, it is usually not necessary to have another pelvic examination. If you make a note of the size of your diaphragm, the health care practitioner who provided it can telephone a prescription for a new one to your pharmacy. The size is usually printed on the rim. It should also be noted in your medical records.

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