Is the diaphragm an option for women seeking non-hormonal birth control? - ABC News

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Quick quiz: What do the classic '90s sitcoms Friends, Sex and the City and Seinfeld all have in common (aside from the fact they're set in New York City)?

They all feature storylines revolving around the now-rarely used form of birth control known as the diaphragm.

These '90s sitcoms may have been fascinated by this particular form of contraception, but only around 1 per cent of American women were actually using the diaphragm in that decade (maybe it's to do with the fact TV writers in the '90s tended to be men, who didn't actually understand how unpopular the diaphragm was). Nowadays it's only used by fewer than 1 per cent of Australian women.

So, why are we talking about it?

Not Just The Pill

Diaphragms are just one of the less popular forms of contraceptives that have actually been around for a while.

The pill has served women around the world for more than half a century, but with evidence suggesting Australian women are looking to other options[1], we decided it was worth taking a closer look at things like the diaphragm.

ABC Life's series Not Just The Pill looks at different methods of contraceptives — like the female condom[2] and fertility awareness methods[3] — how they work, how effective they are and why they haven't become as popular as the pill.

Well, research suggests young Australian women want to talk to their doctors about a range of contraceptive options[4], not just more commonly used hormonal contraceptives and condoms.

Hormonal contraception, like the pill, is one of the most effective forms of birth control. But not all women can, or want to, use hormonal birth control.

The diaphragm is a woman-initiated non-hormonal form of contraception. Unlike the condom, it doesn't require any initiative on the part of a male partner. And unlike the female condom, you can use it over and over.

But despite those benefits, it's still one of the least popular forms of birth control.

Dr Melissa Kang is a sexual health researcher who spent decades answering all manner of questions about sexual health, including many on contraception, for the well-known Dolly Doctor column in the teen magazine. She says that she never gets asked about the diaphragm anymore.

"It's really gone out of fashion in Australia."

But this wasn't always the case.

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A brief history of the diaphragm

The diaphragm was invented back in 1882 and while its use quickly spread across Europe, it remained illegal in the United States until 1936. But that didn't stop birth control activist Margaret Sanger, the founder of Planned Parenthood, who brought the diaphragm to America and illegally distributed it through her clinic in the early part of the 20th century.

Women liked it because it was one of the only reliable forms of birth control that they could control themselves.

Fertility awareness methods of birth controlIs the diaphragm an option for women seeking non-hormonal birth control? - ABC NewsA growing number of Australians are opting for 'natural' contraception methods, including fertility awareness methods. Here's what you need to know.Read more
[5]

In the late 1950s it was the preferred method of contraception for one in five Australian married women[6]. This is a pretty remarkable figure when you consider the fact that the device had to be manually fitted by a doctor.

But women stopped using the diaphragm in the 1960s when the pill came onto the market. The pill empowered women thanks to its extremely high rate of effectiveness. And, unlike the diaphragm, it wasn't invasive.

These days the diaphragm is used by only a tiny proportion of Australian women. A 2016 survey on Australian women's contraceptive choices[7] found only 0.5 per cent of women reported using the diaphragm — a figure that includes usage of the cervical cap, vaginal ring and other methods.

Some women still love the diaphragm. It was Beth's* preferred method of contraception until she was in her 30s and decided she wanted children.

"I started using it because I wanted a 'natural' form of birth control — no synthetic hormones — and I wanted [sex] to feel as good as possible. Condoms just don't feel the same," she says.

Want weekly updates from ABC Life delivered to your inbox? Sign up to our newsletter.[8]

What is the diaphragm?

The diaphragm is a soft, dome-shaped silicone cap with a flexible rim.

"It goes up inside the vagina and sits against the cervix," Dr Kang explains.

This forms a barrier preventing sperm from getting into the uterus and reaching an egg.

Like the male and female condoms, the diaphragm is a barrier method of contraception, which means it physically blocks sperm from fertilising an egg.

Ever considered the female condom?Close up image of hand holding up a female condomThe female condom is much like its male counterpart — but with arguably more benefits. So why is it so hard to find (and so damn expensive)?Read more[9]

But, and this is very important to note, unlike the condom (male or female), the diaphragm isn't a barrier against sexually transmitted infections.

Traditionally, diaphragms needed to be fitted to the correct size by a medical professional. But newer versions of the diaphragm, including those available in Australia, are one-size-fits-all. For more information, consult your GP.

The diaphragm isn't just a physical barrier. It works best when used in conjunction with a spermicide applied to the diaphragm. Spermicides are chemicals that stop sperm from moving, preventing them from getting to an egg. On top of adding further protection, spermicide gel helps hold the diaphragm in place.

Possible side effects[10] for a small number of diaphragm users can include irritation of the vagina or penis. Women using spermicides or diaphragms are also more at risk of UTIs[11] and may want to consider alternative options if they get recurrent UTIs. Rarely, use of a diaphragm might cause toxic shock syndrome.

It's all about timing

Timing is important if you're going to use the diaphragm. You need to:

  • Insert it up to two hours before you plan to have intercourse
  • Leave it in for six to 24 hours afterwards
  • If you want to have sex again within that 24-hour period you need to apply more gel using a plastic implement that looks a bit like a tampon applicator.
Is the diaphragm an option for women seeking non-hormonal birth control? - ABC News
ImageFor every 100 people who use the diaphragm typically over the course of a year, 12 to 18 of them would fall pregnant.(ABC Life: Luke Tribe)

You need to leave the diaphragm in for six hours after sex because sperm can survive inside a woman's body. Exactly how long sperm survive depends on where in the body the sperm is, says medical director of Family Planning NSW Deborah Bateson.

Unlike the uterus, the vagina — the passageway that leads to your cervix and uterus — has a pH level that is slightly acidic during most of your menstrual cycle to help your body ward off potential bacterial infection. That also makes it harder for sperm to survive.

"But once [the sperm] make their way up through the cervix into the upper genital tract, they're into the uterus and the fallopian tubes [where] they can actually survive for generally five days but up to seven days," Dr Bateson explains.

If you were to remove the diaphragm within six hours, there's a chance the sperm could still be active, and could enter into the safety of the uterus.

Furthermore, if you're ovulating, the pH balance of your vaginal fluid will change to assist sperm, which is why the diaphragm's accompanying acid-based gel is important.

How effective is the diaphragm?

Medical director of Jean Hailes for Women's Health Elizabeth Farrell explains most barrier methods (of which the diaphragm is one) are not the most effective methods of contraception.

Birth control effectivenessIs the diaphragm an option for women seeking non-hormonal birth control? - ABC NewsTwo-thirds of Australian women of reproductive age use contraception, yet very few use the most effective method.Read more[12]

"You can't give the same weight to diaphragms, condoms — either female or male — as you can to, say, a Mirena IUD or Implanon," she says. "The comparison is really no comparison, as it were.

"[The diaphragm] is totally imperfect, really, in terms of its failure rate."

The effectiveness of diaphragms can vary by a few percentage points depending on who you reference, but Family Planning NSW reports the diaphragm to be between 82 and 86 per cent effective when taking into account human error (referred to as 'typical use'), like failing to insert it properly.

According to Planned Parenthood[13], the diaphragm is 94 per cent effective with perfect use. But as they point out, "nobody's perfect" and they list the diaphragm as 88 per cent effective with typical use.

For reference:

  • Typical use: The effectiveness of a contraceptive that takes human error into account.
  • Perfect use: The effectiveness of a contraceptive when it is used correctly every time.

What that all boils down to is this simple fact: For every 100 people who use the diaphragm typically over the course of a year, 12 to 18 of them would fall pregnant. And even if 100 people managed to use it perfectly, six would still fall pregnant.

Not the most reassuring of figures.

For context, the condom is 98 per cent effective[14] at preventing pregnancy with perfect use, and 85 per cent effective with typical use. And the pill is 99.7 per cent effective[15] with perfect use, or 91 per cent with typical use.

Is the diaphragm an option for women seeking non-hormonal birth control? - ABC News
ImageUnlike the condom (male or female), the diaphragm isn't a barrier against sexually transmitted infections.(ABC Life: Luke Tribe)
But there are other factors women consider when choosing a contraceptive.

"If somebody wants to have control over when and if they use a contraceptive then obviously the barrier methods are the ones that would fit with that philosophy," Dr Farrell says.

Dr Bateson says the diaphragm's issue is that it has a significant failure rate even if you use it perfectly.

"Which may be acceptable to some women but it may be unacceptable to some other women," she says.

When asked if we might see an uptake in the diaphragm as women increasingly turn to non-hormonal methods of contraception, Family Planning Victoria medical director Kathy McNamee says she hopes not.

"I hope it's more the modern contraceptives [such as the copper IUD], because we only

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