A diaphragm is a rubber cup made of latex or silicone. It is a temporary method of contraception that has been used by women for decades.

Placed over the cervix (the opening of the uterus that separates the vagina from the uterine cavity), a diaphragm is used to stop sperm from entering the uterus and fallopian tube. This is the path where sperm normally travels to fertilize a woman’s egg. The device should always be used in combination with a spermicide cream or gel. When these birth control creams are placed in the diaphragm and along its rim, the spermicide destroys any sperm that may manage to swim around the rim of the diaphragm. A diaphragm does not protect women from sexually transmitted diseases (STDs). To prevent STDs, a condom must be worn by the woman’s partner.

Diaphragms come in many different sizes and types. The four main types include:

• Arcing spring rim diaphragm
• Flat spring rim diaphragm
• Coil spring rim diaphragm
• Wide-seal rim diaphragm

A diaphragm is available only by prescription. A woman is fitted for the device in her physician’s office, usually by her gynecologist. The fit of the diaphragm should be checked every year because changes in the size or shape of the vagina or position of the uterus may cause the diaphragm to fit incorrectly. A number of factors may cause the vagina to change shape or size, including pregnancy and changes in weight.

A diaphragm must be placed into the vagina and onto the cervix before sexual intercourse. It can be inserted up to six hours before sex. Some women use a plastic tool known as an introducer to insert the diaphragm, while others can insert the diaphragm with their fingers. Women may have intercourse several times while wearing a diaphragm. However, additional spermicide should be added each time. After intercourse, the diaphragm must remain in place for at least six hours to prevent pregnancy. It must be removed within 24 hours in order to prevent complications, including urinary tract infections and toxic shock syndrome (TSS).

The Food and Drug Administration (FDA) estimates that approximately 17 percent of women who rely on the diaphragm for contraception have an accidental pregnancy each year. To avoid unplanned pregnancy, a woman must wear the device every time she has intercourse, use spermicide and ensure the device is positioned correctly over the cervix. 

A method of contraception, the diaphragm is a dome-shaped cup made of thin, flexible rubber. It is inserted high into the vagina and placed over the cervix (the area between the vagina and the uterus). By covering the cervix, the diaphragm prevents sperm from entering the uterus and fallopian tube and reaching the egg for fertilization. Proper use of the diaphragm includes placing spermicide in the cup and along its edges before inserting the device. This destroys any sperm that may manage to swim around the rim of the diaphragm. A diaphragm is not designed to protect women from sexually transmitted diseases (STDs). Women can reduce the risk of developing an STD by using the device in combination with a condom.

Made of latex or silicone, the diaphragm is obtainable only by prescription. It is available in a range of sizes and requires fitting by a trained healthcare professional, typically an obstetrician-gynecologist (ObGyn). When the device is properly fitted and inserted, it is held in place by the pubic bone, pelvic muscles and the rear wall of the vagina. The diaphragm is a temporary form of birth control. Its effectiveness ends when it is removed from the vagina. Therefore, a woman may become pregnant any time she has intercourse without the diaphragm or an alternative form of contraception.

The four main types of diaphragm are:

• Arcing spring rim diaphragm. The easiest type of diaphragm to insert, the arcing spring rim diaphragm is very sturdy and has a firm ring. Made of latex, it folds at two hinged points, forming an arc for insertion. Most women can use this type comfortably, including those with poor vaginal muscle tone, rectocele (protrusion of the rectum through the vagina), cystocele (fallen bladder), a long cervix or an anterior cervix with a retroverted uterus.
  
  
• Coil spring rim diaphragm. Made of latex, this type features firm spring strength and a soft flexible rim that does not form an arc when folded. It is suitable for women with average muscle tone and an average pubic arch depth. It can be inserted with a plastic introducer.
  
  
• Flat spring rim diaphragm. This type features a gentle spring stretch. It is similar to the coil spring rim diaphragm, but offers a thinner, more delicate rim. It is most suitable for women with firm vaginal muscle tone. It may also be recommended for women who have experienced an increase in urinary tract infections with previous use of a diaphragm. It can be inserted with a plastic introducer.
  
  
• Wide-seal rim diaphragm. Made of silicone, this type of diaphragm is a good option for women who are sensitive or allergic to latex. It comes in an arcing spring style or a coil spring style. It has a flexible extension that is about 1.5 centimeters (slightly more than half an inch) wide attached to the inner edge of its rim. The extension is designed to form a better seal between the diaphragm and the vaginal wall.

Although diaphragms can be safely and comfortably used by most women, certain factors make the use of a diaphragm less desirable. These factors include:

• A history of toxic shock syndrome (TSS)
• A sagging uterus
• Any discomfort with touching the genitals
• Frequent urinary tract infections
• Poor vaginal muscle tone
• Sensitivity to latex or dry natural rubber products (woman or her partner)
• Abnormal vaginal bleeding (excluding menstruation)
• HIV or a high risk of acquiring HIV
• Difficulty with the insertion process
• Timing of insertion and removal

According to the Food and Drug Administration (FDA), approximately 17 out of 100 women who rely on the diaphragm for contraception have an accidental pregnancy each year. However, the risk of pregnancy depends on whether the woman uses the diaphragm exactly as instructed. For maximum protection, women should:

• Be sure the diaphragm fits correctly and is properly inserted
• Always use spermicide with the diaphragm
• Use the diaphragm every time they have intercourse
• Leave the diaphragm in place for six hours after intercourse
• Replace the diaphragm if it is damaged (e.g., tears, cracks)

For women who fail to follow these guidelines, the effectiveness of the diaphragm decreases to 84 percent.

In order to prevent pregnancy, a woman’s diaphragm must fit properly. Diaphragms are available in a range of sizes from 50 to 105 millimeters (about 2 to 4 inches). Most women use diaphragms measuring between 50 and 95 millimeters (between 2 and 3.7 inches). To determine a woman’s ideal diaphragm size, a trained healthcare professional, typically a GYN, will perform a fitting.

Diaphragm fitting procedures can be performed using diaphragm fitting rings, which are sample diaphragm rims with no dome. A series of fitting diaphragms with a hole in the middle of each dome may also be used. The physician will wear examination gloves and use lubricating gel during the fitting. The patient will be asked to lay with her legs in stirrups and her buttocks near the edge of the examination table (dorsal lithotomy position). To estimate the diaphragm size a woman will need, the physician will:

1. Insert the index and middle fingers into the patient’s vagina until the middle finger reaches the posterior fornix (back wall of the vagina).
   
   
2. Use the tip of the thumb or an instrument to mark the spot where the bony inferior pubic arch touches the index finger.  
   
   
3. Keep the 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 physician has estimated an ideal size, he or she will insert a sample diaphragm in that size into the patient’s vagina. During this process the physician 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 the vulva open with one hand, while using the other hand to insert the folded diaphragm into the 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 the vagina. Its rim should be in contact with the lateral walls of the posterior fornix, but there should not be tension with the 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. It is important to find the proper size because having a diaphragm that is larger or smaller than needed may lead to numerous complications. A diaphragm that is too large can cause:

• Irritation or discomfort
• Leakage
• Buckling
• Vaginal pressure
• Abdominal pain or cramping
• Cramping
• Vaginal ulceration
• Recurrent urinary tract infections (UTIs)

Because the vagina gets longer during arousal, a diaphragm that is too small may slip off the cervix during sexual intercourse, resulting in inadequate protection.

Once a size has been selected, the patient may be asked to practice insertion, positioning and removal of the diaphragm under supervision. The patient may repeat the steps until she and her physician are confident that she is wearing the diaphragm correctly. The physician may ask the patient to practice at home and make a follow-up appointment to check that she is using it properly. It is important that the patient know exactly how to use the diaphragm because an incorrectly inserted diaphragm can result in pregnancy.

Once a year, a physician should examine the patient and determine that the diaphragm is still fitting correctly. The size and shape of a woman’s vagina may change for a number of reasons. A diaphragm that fit perfectly may no longer fit properly after:

• Abdominal or pelvic surgery
  
  
• A weight gain or loss of 10 pounds or more 
  
  
• Full-term pregnancy
  
  
• Miscarriage or abortion (after 14 weeks of pregnancy)
  
  
• Beginning to have intercourse (the diaphragm was fitted when the woman was a virgin)

After an initial phase of instruction and practice, most women are able to insert and remove their diaphragm with ease. Proper use involves applying spermicide to the device and placing it deep inside the vagina so that it securely covers the cervix.

A woman may insert a diaphragm up to six hours before intercourse. Before insertion the woman should:

1. Wash the diaphragm (initial use only). It should be cleansed with mild, non-perfumed soap and warm water, rinsed and dried carefully.
   
   
2. Empty her bladder and wash her 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. The device should not be used if cracks or holes are discovered.
   
   
4. Place spermicide in the cup of the diaphragm. The amount of spermicide necessary is determined by the manufacturer of the spermicide.
   
   
5. Use her fingertip to spread some of the spermicide around the rim of the diaphragm (the side that will be in contact with the cervix). Avoid applying too much spermicide to the rim. Doing so may result in difficulty controlling the diaphragm during insertion.

To insert the diaphragm into the vagina, a woman should:

1. Assume the most effective position. A diaphragm can be inserted while standing with one leg up on a stool, squatting or lying down. Women who are used to one position and then change to a different position need to be particularly careful that the cervix is covered when positioning the diaphragm. The position of the cervix and the walls of the vagina will differ depending on the woman’s position.
   
   
2. Hold the diaphragm with the dome down (spermicide side up) and press the opposite sides of the rim together between the thumb and third finger. The device may be held from above or below.
   
   
3. Use the free hand to separate the lips of the vagina.
   
   
4. Hold the folded diaphragm with the dome down (spermicide side up) and push it gently into the vagina.
   
   
5. Guide the diaphragm along the rear wall of the vaginal canal, guiding it backwards as far as it will go behind the mouth of the cervix. The index finger should remain on the outer rim of the diaphragm to help guide the device into place.
   
   
6. Push the rim of the diaphragm up until it “locks” into place behind the pubic bone.
   
   
7. Run the index or middle finger over the diaphragm’s dome to verify that it is covering the cervix and held in place by the upper edge of the pubic bone and the rear wall of the 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. To prepare a diaphragm for insertion with an introducer, a woman will follow the same instructions for washing and inspecting the diaphragm and then:

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.

To insert the diaphragm into the vagina with an introducer, a woman will:

1. Insert the introducer into the vagina, with the spermicide side facing up.
   
   
2. Guide the inserter along the rear wall of the vaginal canal, guiding it backwards until the diaphragm has been inserted as far as it will go behind the mouth of the cervix.
   
   
3. Once the diaphragm is in place, twist the introducer slightly to the left or right to release the diaphragm.
   
   
4. Slowly withdraw the introducer from the 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 the pubic bone.
   
   
6. Run an index or middle finger over the diaphragm’s dome to verify that it is covering the cervix. If the device is in the 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.
   
   
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.

In order to prevent pregnancy, the diaphragm must be left in place for at least six hours following intercourse. Women may have intercourse more than once while using the diaphragm. However, more spermicide must be used each time. The spermicide should be inserted into the vagina, without removing the diaphragm, using a spermicide applicator. Movement and changes in position should not move a properly inserted diaphragm. However, if a diaphragm becomes uncomfortable, a woman should check to be sure it has not moved out of position. A woman can shower or bathe while the device is in place, as well as urinate and have a bowel movement.

To prevent infection and other side effects, the device must be removed within 24 hours.

To remove the diaphragm, a woman will:

1. Insert the index finger inside the vagina and place it behind the front rim of the diaphragm.
   
   
2. Pull the diaphragm downward and out of the 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, a woman 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 the vaginal wall and the rim of the diaphragm. Women should take care not to tear the rim or pierce the rubber with a fingernail during arousal. 

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.

The diaphragm offers women a variety of potential benefits, including:

• Reusable and less expensive than many other forms of contraceptives
  
  
• Does not interrupt intercourse because it can be inserted hours ahead of time
  
  
• Usually cannot be felt by the woman or her partner
  
  
• Allows the woman to control contraception
  
  
• Can easily and discretely be carried in a pocket or purse
  
  
• Causes fewer side effects than hormonal forms of contraceptives
  
  
• Safer than birth control pills for women with certain medical conditions and women over age 35 who smoke
  
  
• Is a temporary form of contraception that does not interrupt or alter fertility
  
  
• Is effective immediately
  
  
• Can be used during breastfeeding

As with most forms of contraception, use of a diaphragm has been linked to a number of risks. Although most women who use a diaphragm have no complications, possible risks include:

• Allergic reaction. Some diaphragms are made of latex, a material that may trigger an allergic reaction. Diaphragms made of silicone may be used as an alternative.
  
  
• Urinary tract infection (UTI). Use of a diaphragm has been linked to an increased risk of developing UTIs. Emptying the bladder immediately following intercourse, and not wearing the diaphragm for more than 24 hours, can lower the risk.
  
  
• Yeast infection and other infections. Use of a diaphragm has been linked to an increased risk of developing yeast infections, as well as other vaginal infections including bacterial vaginosis.
  
  
• Sexually transmitted diseases (STDs). Diaphragms do not offer full protection against STDs. Condoms must always be used in combination with a diaphragm to protect against STDs.
  
  
• Irritation from spermicide. The spermicide used in conjunction with the diaphragm may cause irritation in the vagina and the surrounding skin.
  
  
• Strong odors or vaginal discharge. These complications may appear when the diaphragm is left in the body for too long. To prevent unusual odor and discharge, women should not wear the diaphragm for more than 24 hours.
  
  
• Toxic shock syndrome (TSS). Caused by a toxin produced by certain types of bacteria, TSS is a condition that has been linked to diaphragm use. Although it is rare, TSS is a serious disease. Women can prevent the condition by removing their diaphragm within 24 hours of insertion. 
  
  
• Pregnancy. The diaphragm is not 100 percent effective in preventing pregnancy. It is less effective than hormonal forms of contraception, including birth control pills, injections and patches. 
  
  
• Discomfort. Although most women and their partners do not feel the device, the diaphragm may cause discomfort for some people.
  
  
• Inconvenience. The diaphragm does not offer continuous birth control protection and must be inserted prior to sexual intercourse. Although it can be inserted up to six hours prior to intercourse, many women feel the timing is inconvenient. In addition, a woman must have her diaphragm and spermicide with her if she thinks she may have intercourse in a location other than where she keeps her birth control supplies. Spermicidal foams, creams and jellies also may be messy to use.
  
  
• Abnormal Pap test results. Use of a diaphragm has been linked to an increased incidence of abnormal Pap test results, specifically hyperkeratosis. Hyperkeratosis means that dry skin cells were found on the Pap test, and the patient may require a repeat test in six months to one year.
  
  
• Spotting. Use of a diaphragm may cause spotting (abnormal vaginal bleeding). Also, there may be increased vaginal discharge from the spermicidal creams used with the diaphragm.

For women who are candidates for use of a diaphragm, there are certain responsibilities that accompany the decision. In order to properly and effectively use the device, women 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, women choosing to use the diaphragm as a form of contraception must always have a supply of spermicide. Semen dilutes spermicide. Therefore it should be inserted before any additional sexual intercourse occurs. Condoms also should be used for protection from sexually transmitted diseases, particularly if the woman is not in a committed relationship or she is unsure of her partner’s sexual history.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about diaphragms:

1. Am I a candidate for a diaphragm?
   
   
2. How long does it take to be fitted for a diaphragm?
   
   
3. What type of diaphragm is best for me?
   
   
4. What type of spermicide do you recommend for use with a diaphragm?
   
   
5. What are the risks associated with using a diaphragm?
   
   
6. How much do diaphragms cost?
   
   
7. How long will a diaphragm last?
   
   
8. Should I have more than one diaphragm in case of damage?
   
   
9. How can I tell if my diaphragm is in the correct position?
   
   
10. What should I do if I notice the diaphragm is out of place after intercourse?
    
    
11. What should I do if I’m unable to remove my diaphragm?
    
    
12. What is the best way to clean and store the diaphragm?
    
    
13. How often should I be fitted for a new diaphragm?
    
    
14. Is it safe to use a diaphragm after childbirth?
    
    
15. What signs might indicate a serious medical condition from diaphragm use?