Diaphragm: Dealing Day-to-Day

Reviewed By:
Joanne Poje Tomasulo, M.D., ACOG

If you are a candidate for use of a diaphragm, there are certain responsibilities to keep in mind that accompany the decision. In order to properly and effectively use the device, you must be able to take responsibility for intercourse in advance. The device must be inserted before intercourse and removed from the body after intercourse within a certain time frame.

In addition, if you choose to use the diaphragm as a form of contraception, you must always have a supply of spermicide. Semen dilutes spermicide. Therefore, it should be reapplied before any additional sexual intercourse occurs. Other tips include:

1. Take proper care of your diaphragm

Diaphragms should be replaced every one to two years. There are steps you can take to properly care for you diaphragm and ensure that it lasts for two years.

You should avoid any substances that may damage the rubber and cause the diaphragm to become brittle and crack. Damaging substances include:

• Oil-based lubricants. These include petroleum jelly, baby oil, cocoa butter and hand lotion. Water-based lubricants should be used instead.
  
  
• Baby powder.
  
  
• Vaginal creams. These include hormone creams and those used to treat yeast infections.

To avoid damaging your diaphragm, you should discuss the use of all lubricants and vaginal creams with your doctor, pharmacist or the manufacturer of the diaphragm.

In addition, proper diaphragm care includes:

• Careful handling to avoid fingernail damage. You should handle the diaphragm carefully to avoid stretching or puncturing the device with sharp fingernails.
  
  
• Not douching. You should not douche until the diaphragm is removed.
  
  
• Cleaning properly. Only warm water and non-perfumed soap should be used to clean a diaphragm. It should never be boiled or cleaned with antiseptic solutions.
  
  
• Storing properly. The device should be stored, unrolled, in its original container. It should not be allowed to dry in the open because prolonged exposure to heat and light may deteriorate the material of the diaphragm.

2. Make sure your diaphragm fits properly

It is very important for the initial sizing of your diaphragm to be accurate. Your diaphragm will also need to be resized annually. You should know what to expect when your diaphragm is sized. To estimate the diaphragm size you will need, your doctor will:

1. Insert his or her index and middle fingers into your vagina until the middle finger reaches the posterior fornix, or the back wall of your vagina.
   
   
2. Use the tip of his or her thumb or an instrument to mark the spot where the bony inferior pubic arch touches the index finger.
   
   
3. Keep his or her fingers in position as they are withdrawn from the vagina.
   
   
4. Estimate a size. The fitting ring or diaphragm is placed with the rim over the end of the middle finger, and the opposite side of the rim is extended to the marked position on the index finger.

Once the doctor has estimated an ideal size, he or she will insert a sample diaphragm in that size into your vagina. During this process the doctor will:

1. Lubricate the rim of the fitting ring or diaphragm and then fold the device in half so that the two sides of the rim are touching.
   
   
2. Hold your vulva open with one hand, while using the other hand to insert the folded diaphragm into your vagina and direct placement toward the posterior fornix.
   
   
3. Examine the location of the cervix through the middle of the fitting ring or the dome of the fitting diaphragm to verify proper placement.
   
   
4. Push the anterior rim of the diaphragm so that it fits directly behind the pubic bone.

A perfectly fitting diaphragm should sit snugly in your vagina. Its rim should be in contact with the lateral walls of the posterior fornix, but there should not be tension with your vaginal walls. There should be enough room to place one finger tip comfortably between the inside of the pubic arch and the anterior edge of the diaphragm rim.

To determine the ideal diaphragm size, a number of different sized diaphragms may be tested. The diaphragm should be the largest size that can be comfortably inserted, worn and removed by the patient.

3. Properly insert your diaphragm

Once your diaphragm has been properly fitted, you must know how to properly insert it. You may insert your diaphragm up to six hours before intercourse. Before insertion, you should:

1. Wash the diaphragm. This is important for the initial use only. Your diaphragm should be cleansed with mild, non-perfumed soap and warm water, rinsed and dried carefully.
   
   
2. Empty your bladder and wash your hands.
   
   
3. Inspect the diaphragm for cracks or small holes. It may be held up to light or filled with water to detect these flaws. Do not use your diaphragm if cracks or holes are discovered.

If using a typical diaphragm (without an introducer), your preparation and insertion should proceed as follows:

1. Place spermicide in the cup of the diaphragm. The amount of spermicide necessary is determined by the manufacturer of the spermicide.
   
   
2. Use your fingertip to spread some of the spermicide around the rim of the diaphragm, or the side that will be in contact with your cervix. Avoid applying too much spermicide to the rim. Doing so may result in difficulty controlling the diaphragm during insertion.
   
   
3. Assume the proper position. A diaphragm can be inserted while standing with one leg up, squatting or lying down. If you are used to one position and then change to a different position, you need to be particularly careful that your cervix is covered when positioning the diaphragm. The position of you cervix and the walls of your vagina will differ depending on your position.
   
   
4. Hold the diaphragm with the dome down (spermicide side up) and press the opposite sides of the rim together between your thumb and third finger. The device may be held from above or below.
   
   
5. Use your free hand to separate the lips of your vagina.
   
   
6. Hold the folded diaphragm with the dome down (spermicide side up) and push it gently into your vagina.
   
   
7. Guide the diaphragm along the rear wall of your vaginal canal, guiding it backwards as far as it will go behind the mouth of your cervix. Your index finger should remain on the outer rim of the diaphragm to help guide the device into place.
   
   
8. Push the rim of the diaphragm up until it locks into place behind your pubic bone.
   
   
9. Run your index or middle finger over the diaphragm's dome to verify that it is covering your cervix and locked in place by the upper edge of your pubic bone and the rear wall of your vagina. If the device is in correct position, the cervix should be easily felt through the rubber. It will feel like the end of a nose. It is normal to detect folds in the diaphragm when it is in place.

The coil and flat spring styles of diaphragm may be inserted with a plastic tool known as an introducer. The tool may be used to hold one side of the diaphragm's rim. In addition to the preparation steps above, you will also need to complete the following before inserting a diaphragm with an introducer:

1. Hold the introducer in one hand, with its notched side facing down.
   
   
2. Hold the diaphragm in the free hand with the dome down (spermicide side up).
   
   
3. Squeeze the opposite sides of the diaphragm together and place one end of the rim into the notched end of the introducer.
   
   
4. Fit the other end of the diaphragm over the notch corresponding to the diaphragm's size. Sizes are shown next to each notch on the introducer.
   
   
5. Turn the introducer over and insert the necessary amount of spermicide into the fold formed on the dome side of the diaphragm. The necessary amount spermicide is determined by the manufacturer of the spermicide.
   
   
6. Use a fingertip to spread some of the spermicide around the rim of the diaphragm -- the side that will be in contact with the cervix. This will make insertion easier and help fasten the diaphragm in place.

Proper insertion of a diaphragm with an introducer should proceed as follows:

1. Insert the introducer into your vagina, with the spermicide side facing up.
   
   
2. Guide the inserter along the rear wall of your vaginal canal, guiding it backwards until the diaphragm has been inserted as far as it will go behind the mouth of your cervix.
   
   
3. Twist the introducer slightly to the left or right to release the diaphragm once the diaphragm is in place.
   
   
4. Slowly withdraw the introducer from your vagina.
   
   
5. Insert an index or middle finger into the vagina and use it to determine if the near rim of the device is pushed up behind your pubic bone.
   
   
6. Run an index or middle finger over the diaphragm's dome to verify that it is covering your cervix. If the device is in the correct position, your cervix should be easily felt through the rubber. It will feel like the end of a nose. It is normal to detect folds in the diaphragm when it is in place.
   
   
7. Wash the introducer with soap and warm water, rinse and dry.

Once in the body, the diaphragm should fit comfortably. Any discomfort or pain while the device is in place may indicate that it has been placed incorrectly or that it is the wrong size.

4. Properly remove your diaphragm

To prevent infection and other side effects, you must remove your diaphragm within 24 hours. To remove your diaphragm, you should:

1. Insert your index finger inside your vagina and place it behind the front rim of the diaphragm.
   
   
2. Pull the diaphragm downward and out of your vagina.
   
   
3. Wash the diaphragm with non-perfumed soap and warm water. Rinse and dry it carefully.
   
   
4. Return it to its original container and store it in a dry, cool place.

In some cases, you may have difficulty reaching the rim of the diaphragm. Straining down, as with a bowel movement, may force the rim down, making it easier to reach. Suction may also make removal difficult. However, the suction may be broken by placing a finger between your vaginal wall and the rim of the diaphragm.

Although a properly placed diaphragm usually stays in place, some women may discover that their diaphragm is not in the correct position when they go to remove it after intercourse. An incorrectly positioned diaphragm may result in conception, and emergency contraception may be needed to prevent pregnancy.

It may take some getting used to, but with practice you should eventually be able to insert and remove your diaphragm without any trouble at all.