Where’d the Diaphragm Disappear To?

Did you know that last year’s combined sales of Yaz and Yasmin, the most popular oral contraceptives in the U.S., totaled $1.64 billion? Did you know the drugs are also the target of 1,100 lawsuits for potentially fatal blood clots? Did you know that an estimated 50 women have died from taking those contraceptives?

Despite such health risks, however, oral contraceptives remain an extremely popular method of birth control in the U.S., second only to sterilization. The Guttmacher Institute reports that whether a woman prefers the Pill or sterilization is largely a function of age, with women under 30 choosing the Pill and women over 30 choosing permanent methods. These trends have been fairly stable since 1982.

None of these facts surprised me as much as the news that fewer than one percent of women in North America (and northwestern Europe) use the diaphragm–or any other woman-controlled barrier method. I’m puzzled that a safe, reliable, fairly easy-to-use (with some training and practice), inexpensive method of controlling fertility is not more widely recommended. Used correctly and consistently, the diaphragm has an effectiveness rate of 94 percent. Nevertheless, diaphragm use declined after the Pill was introduced, from 25 percent of married women in 1955 to 10 percent in 1965, and kept dropping thereafter, to just 4.5 percent of all women in 1982 and 0.2 percent today, according to the CDC [pdf].

U S. Medical Eligibility Criteria for Contraceptive Use, 2010, released last month by the Centers for Disease Control, shows that the diaphragm has no medical contraindications for most women. The exceptions are latex allergies, immediate postpartum or post-termination use, uterine prolapse and women with HIV/AIDS, for whom the risk is not the diaphragm itself but the accompanying spermicide nonoxynol-9, which may increase viral shedding and HIV transmission to uninfected sex partners.

Yet the American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice recommends that hormonal methods such as IUDs or injections be offered as “first-line contraceptive methods and encouraged as options for most women.” At this year’s annual ACOG meeting last month in San Francisco, the group issued a press release with eight gushing statements of praise for the Pill on its 50th anniversary.

But nearly four of every ten women who use contraceptives are not satisfied with their method, and I hear frequently from young women that they’re pressured at college health centers and physicians’ offices to choose hormonal methods, usually the Pill, over barrier methods such as condoms and diaphragms. Even after negative experiences with the Pill, women are often encouraged to try another brand rather than another method.

I’ve even heard of educators and health care providers actively discouraging use of the diaphragm because “it’s messy”. This complaint baffles me, and I used a diaphragm for 15 years. With or without a diaphragm, sex is messy.

Although diaphragms must be accurately fitted by a health care professional and re-assessed every few years, they remain cheaper than hormonal methods and require less frequent physician visits. A diaphragm can be inserted hours or moments before intercourse, and it is a fully reversible, female-controlled method of birth control. There is some evidence that diaphragm use minimizes women’s exposure to certain STIs , and ongoing research by pharmaceutical companies is aimed at developing a spermicide that is also antimicrobial.

There’s even research on a one-size-fits-all diaphragm in progress: Program for Appropriate Technology in Health (PATH) has developed and patented a single-size diaphragm designed to fit most women comfortably. The modified device has proven effective in initial studies, and the organization plans to apply to the FDA for approval as a contraceptive by the end of next year.

Early last century, Margaret Sanger risked prison to introduce the diaphragm to an American public desperate for effective birth control. We need a contemporary crusader to re-introduce the diaphragm in the 21st century for those seeking safe, effective, hormone-free birth control.

Photo courtesy of Jenny Lee Silver under Creative Commons 3.0.

Crossposted from the Society for Menstrual Cycle Research.

Comments

  1. I’m glad to see that Ms. is publishing a diversity of opinions on birth control options rather than just hormonal methods. You’re not the first to suggest that hormonal methods are oversold. [even on this blog -- e.g. the article on emergency contraception] By the way, Margaret Sanger was a major supporter of research that led to the development of the first oral contraceptives and secured funding from her friend Katherine McCormick at a time when no drug company or government agency was willing to fund this research.

  2. I reacted badly to every version of the pill I was put on and only offered different versions or brands. I actually had to ask about a diaphragm and was told that it had to be fitted, that I had to make a special appointment, it might take a lot of getting used to and that I should consider trying a newer version of a low-dose hormone. When I went for the fitting the Dr confessed that she had not done one in some time as they are not very popular with her patients; truly it was an uncomfortable experience. Still I would not ever go back. The pill was surely an important step for women, but it is not for everybody. It definitely was not for me.

    • dear joy- i am a happily married woman 43 years old. my mother recommended me to get fitted for a diaphragm when i came back from my honeymoon , and that was 24 years ago. after using it sucessfully for 2 years i decided to get pregnant with my first of 2 children. 3 years ago after using many different types of b.c. pills for which i had all kinds of problems with i decided to get fitted with a diaphragm and use it for contraception until i reach menapause. i had to find a older phisician that had experience in fitting diaphragms. he recommended that i use a milex wide-seal diaphragm and believe it or not it was the same size that i used after getting married a #65 and that was because both of my children were borne by c-section. my husband have a great sex life ,a least 3 times a week and as a woman i really enjoy using my diaphragm for protection.

    • zannelaw says:

      Not for me either. And i couldn’t get an IUD. My doctor even forgot about the diaphragm because nobody has one anymore. Thank god she thought about it! I think it’s fine. So much better than the hormones!!!

    • dear carol- thank you for your comments about using the diaphragm, I am similar to you. I started using b.c. pills when I got married and that was 15 years ago . during that time I must have had 6 or 7 different kinds of pills and had all types of bad side effects spotting,headaches,weight gain,lost my sexual libeto and many more. for the past 2 years I have using the milex wide-seal diaphragm with contraceptive jelly. although it a little messy and my husband and I have sex at least 3 times a week we both love using it. I have a diaphragm in my night stand and my husband has one in his. he can insert it in me just as good as I can, less than 2 minutes in the dark bedroom. about 2 times during the week when I take a shower in the morning I will douche using my douche bag, some people say its not good for you but I have never had any problems from douching to much.

  3. I recently got a copper IUD after having my 3rd child. My doctor really tried to pressure me to get the Mirena IUD. Why? I am pretty sure she was getting paid. I told her I was concerned with taking hormones into my thirties, and I got pregnant because I kept having problems with the pill. She kept having me try a different one which only seemed to change the problems. All the pills were making my excema act up and causing me to get really dry vagina. Not fun! Anyway I said no thanks. She said I would have horrible periods for 10 years, but that hasn’t happened at all in the past 6 months. A friend got the Mirena the same time and she is still bleeding. She’s been bleeding almost constantly for 6 months. So glad I said no, and I love my Copper IUD!

  4. Ecobabe says:

    No argument that hormonal methods have potentially hazardous side effects — but it doesn’t really strike me as that odd that women don’t prefer a barrier method instead. I can give you plenty. I’m allergic to latex, and in my experience polyurethane condoms break like crazy (which leads to you either crossing your fingers and hoping a lot or resorting to a hormonal method like Plan B). I have a silicone diaphragm, but it’s not particularly effective on it’s own and I find Nonoxynol-9 irritating, too. Barrier methods also impede spontaneity and are somewhat more difficult to use effectively (not impossible, but the Pill is a lot harder to mess up). No one should be strong-armed into using any birth control method they don’t prefer, but I can totally understand the reasons why hormonal methods appeal to many people. And if you’re a doctor thinking that people are going to skip using the barrier method b/c it’s inconvenient and/or not use it correctly, it doesn’t seem that strange that you might also recommend a hormonal method. Even though I now use a barrier method, I used the Pill for many years, loved it, and didn’t suffer any obvious negative short-term effects. The only reason I switched was because I had given birth and breastfed my daughter for 3 years after that.

  5. I loved my diaphragm. But I switched to the pill because the spermicide made oral sex quite unpleasant for my partner. Is that still an issue?

  6. 94% for *perfect* use – that’s just NOT enough for anything other than a back up method.

    I think that’s why non-hormonal IUDs are so popular in Europe. I had one for a while and now I’m trying the hormonal one.

    I don’t want to be pregnant, I don’t want to deal with deciding what to do about a pregnancy, I don’t want to wait for my period every month and worry about it even a little. I’m no fan of hormones (I’m even skeptical of the very low dose in the mirena iud and I wouldn’t have tried it if I couldn’t easily go back to copper). But %99.4-7 (‘average use’ versus %94 (perfect use) feels like a BIG difference in risk level to me.

  7. Nectarine says:

    A good article, but I take issue with one small thing.  You mention women “choosing” permenant methods (sterilization) based on age.  While this is likely true in many cases, in my experience, the younger a woman is the more difficult it will be for her to find a doctor willing to perform a tubal ligation.
    I met one woman recently who had two children by the age of 24, and did not want any more but her doctor refused to do the procedure, and refused to refer her elsewhere for it.  He reportedly told her that since she was young she would likely “change her mind” at some point!

    Maybe another post for another day? I live in Canada, but I’m going to go out on a limb and guess that this situation is likely much the same in the US.

  8. In my late 40s in New Zealand, I recently stopped taking the pill and decided to get sterilized. Meantime, I called the local Family Planning clinic to get a diaphragm — I’d used one in my 20s successfully. I was told that they had just that week decided they would no longer be offering them because they were too hard to get hold of from suppliers and that no one made the spermicide anymore. Now, I don’t know how true this is, but I was pretty shocked (and annoyed). So, now there’s less choice, not more.

  9. Thanks for all of the responses!

    @Knitting Clio – the story of how Margaret Sanger and Katherine McCormick (of the Chicago “International Harvester” McCormicks) funded the Pill is told in the PBS film, “The Pill”. It’s a well-done film, and I’ve used it several times in teaching classes about sexuality and gender.

    @Joy and @Polly – thanks for sharing your stories. Every time I talk about this issue, I hear more such examples.

    @Ecobabe – you’ve raised some good points about preferences for particular methods, but I think what troubles me most isn’t so much which choices people make as the lack of adequate information to make a choice.

    @woodscolt – It’s been several years since I last used a diaphragm, but I suspect that’s still an issue, albeit fairly easily resolved with timing. (That is, insert the diaphragm *after* oral sex.)

    @Tara – Everyone has a different threshold of acceptable risk. I note, however, that 99% effectiveness for the pill is also a “perfect use” statistic; in actual use, women miss an average of 2-3 pills per month.

    @Nectarine – Good point! I thought such invasive questioning of women seeking sterilization had diminished, but I could be wrong. There’s probably some regional as well as national variation.

    @Wilma – I don’t know how common that experience is, but I’ve heard a couple more anecdotal examples since publishing this piece!

  10. NYCprochoiceMD says:

    So much misinformation here.

    Yes, there is a small (but not nonexistent) risk of stroke, cardiovascular events, and blood clots with oral contraceptives. These risks are greater in older women, obese women, and smokers. However, women who are pregnant are much more likely to have these complications than women using hormonal birth control methods. Preventing pregnancy with highly effective methods actually decreases the risk of these events.

    The diaphragm is certainly not a good method of contraception. Most providers discourage its use not because it’s messy, but because the risk of pregnancy is unacceptably high in the presence of other more effective methods. Fully 15-25% of women using the diaphragm will get pregnant in a year. Those are not good odds for someone serious about not getting pregnant.

    I agree that many women are unhappy with their contraceptive method, and that highly effective female-controlled barrier methods should be a priority for research (though I have heard that the new female condom is an improvement over the prior one). As much as we would like it to be, the diaphragm is not the answer. For now, hormonal methods are among the most effective when taken correctly, and although there are risks, being pregnant is far more dangerous than any hormonal contraceptive.

  11. Female condoms are vaginal barriers with several important advantages over diaphragms: they're cheap, easier to get (no dr. visit or Rx is required), easier to insert and remove, disposable, AND help prevent STIs. Effectiveness rates are comparable.

  12. I wonder how much of the failure rate in diaphragms is from not having one properly fitted. When I had mine fitted it really was a matter of putting various diaphragms in. Then I, followed by a nurse, checking to see if it was snug. You also need to be comfortable enough with your body to check that it's properly over your cervix and then check again after sex. Cervixes certainly move around during the month.

    A proper fit is crucial. Of the women I know who have properly fitting diaphragms none of us have got pregnant. I know of a friend's mother who got pregnant because the diaphragm was totally the wrong size and it was too difficult to manipulate the dinner plate. A bad fitting diaphragm will protect you as much as inconsistently taking the pill.

    And lets not forget that the pill can influence your mind and who you find sexually desirable! for some the pill is a powerful mood stabilizer and a handy tool, but it disturbs me how lightly chronic use of a mind altering substance is prescribed. Pregnancy is generally more mind altering and dangerous, it's a risky thing for your body to do and no one stays pregnant for years and years on end.

  13. Butterflymama says:

    My issue is definitely that barrier methods aren't as effective. I got pregnant from a condom malfunction (I now have a beautiful 8 month old that I love and wouldn't trade for anything) when I wasn't trying to get pregnant. I've had a lot of issues with hormones and side effects and since I couldn't manage to use an instead cup for my period I doubt I could maneuver a diaphragm over my cervix. I am not using the Paraguard IUD and hoping it will be my answer. Researchers need to focus on coming up with male contraceptives or something. I've told my husband after we have the second baby we are either having the rest of our kids close together or he is getting a vasectomy because I am D O N E.

  14. Flo Lenhard says:

    I was a diaphragm user for more than 20 years (because it worked.) My son is 41 and was a happily desired baby by his daddy and me. My only diaphragm failure was when I left the diaphragm in my car outside which, among other things, indicated to me that I was very fertile.
    I am 68 now, don't need the diaphragm or anything, have lost my desire for sex, write good poetry instead.

    • dear flo- thank you for your comments about the diaphragm. I have also used a diaphragm sucessifully for many years. I tried using several types of birth control pills and I had horrible side effects from all of them. just recently a friend of mine suggested that I try using a femcap. so far I really like using it, I have a very active sex life my husband wants to do it to me almost every night. we have 2 children ages 23 and 21 so I surely don’t want to have a accidential pregnancy at my age (43) .

  15. My doctor, in my late 20s, strongly discouraged sterilization, not because of my age, but because male sterilization is far more effective and safer (female sterilization is safest immediately after delivery). I ended up not getting sterilized though, for other, unplanned reasons.

    Right now I am very happy with the paraguard. Regarding the mirena, after the period of bleeding has stopped, most likely periods will become almost nonexistant.

    Regarding heavier periods with paragard – I had a wee bit heavier ones the first two, and my current one has seemed to have slowed down…

    Every woman’s body will react differently to different methods.

    Oh and for those of us that can use a diaphragm, they work rather well as reusable menstrual cups on lighter days. ;) I am not a fan of the spermicide though, as it irritates my skin. I am very happy with the paragard – 10 years + no hormones. :)

  16. I use a diaphragm and am extremely happy with it. The hormones never worked for me, I had side effects no matter which kind I tried. I too felt that hormone methods were really pushed on to me, everywhere I went. I even had one doctor laugh at me when I suggested the diaphragm! I finally found a nurse practitioner who listened to me, and told me the diaphragm was a good, and viable method, and that she didn’t know why more women weren’t using them! I have been happy with my birth control method ever since…

  17. I am so glad to see this article as I wonder the same thing. I used a diaphragm successfully for many years and found it very easy. Once in I didn’t feel it and when I didn’t need it I wasn’t messing with my body or cycles ‘just in case’. For those who have problems with commercial spermicides you can make an effective one yourself – look for recipes with lemon juice. The Pill: Are You Sure It’s For You? has several recipes. As for the 94% effectiveness rate – as many women know the pill isn’t as effective as touted, with a user effectiveness of 92-94% per year, which equates to a 60-80% chance of an unplanned pregnancy if a woman uses it for 10 years. No method is 100% so I believe it’s important to find a method you’re happy with and are comfortable using, which will certainly be different for different women and couples.

  18. user12345 says:

    Thank you for this article. I’ve been wondering why my friends started having acne problems in their mid 20′s, and my guess was that it may have been the Pill. I have clear skin, and don’t even want to take any chances with the Pill. I don’t want to experience breakouts, or weight gain, etc. I don’t know why people want unnatural hormones in their systems. People seem so trusting of doctors. I am the only person who thinks that doctors have hidden motives for pushing certain prescriptions on their patients? I know it sounds so horrible to think this way and certainly not all doctors are the same.

  19. I used a diaphragm as my only method of contraception from the birth of my son in 1977, through divorce and new partners (even in the passionate throes of “falling madly in love”) for more than 30 years. Occasionally I heard that he could feel it, but it never interfered with anyone’s pleasure, never bothered anyone during oral sex, and I owned my fertility and my body. One GYN told me that I was a great advertisement for correctly using it. Maybe I’m a bit of a control freak, but I can’t imagine birth control that’s not precisely associated with sexual activity and under MY purview.

  20. DeLani Bartlette says:

    It’s all about choice…I used a diaphragm for about a year after I gave birth to my son because I was breastfeeding and I *hated* it. It was annoying to deal with, difficult, and uncomfortable. Some women love it, and that’s great for them. Keep diaphragms in the line-up. But not everyone likes having to deal with it.

  21. Thank you for this posting.. I’ve read all of the comments and have found them thoughtful and resonant, but there’s one thing that nobody ever mentions about the pill, or other hormonal methods, that I would like to address .. (I was on the pill for 12 years) .. The Pill KILLS my sex drive!!! (and I don’t think I’m the only one). It wasn’t a problem for many years and then all of a sudden.. it was a problem.
    I almost felt numb down there.. and it wasn’t just my sex drive.. I felt like the pill killed my lust for life in general… I felt that it deadened my personality and made me feel very heavy and humorless. I got off the pill many years ago but recently decided to give the Nuvaring a try.. same problem only WORSE!! and actually, because I got on the Nuvaring and then off of it again fairly quickly, my natural cycle was disturbed and I ended up getting pregnant because I lost track of my ovulation schedule. I wish that somebody had given me other options years ago.. a non-hormonal IUD would’ve probably been a good idea. At this point I’m going to give the diaphragm a try and hope for the best… I’m not ready for a baby quite yet!!

  22. Because I have Factor V Leiden (a mutation that greatly increases the risk of blood clots) and a history of blood clots, my doctor told me that she doesn’t feel comfortable prescribing any hormonal contraceptives to me whatsoever; no pills, no IUD, no Depo shots. I’m only 26 years old, so this was a real shock.
    My doctor encouraged me to consider a diaphragm. I’m was thrilled that there’s a contraceptive option that doesn’t involve hormones or messing up my natural cycle. I’m aware that the diaphragm is not as effective as oral contraceptives, but 96% effective is WAY better than just crossing my fingers and hoping for the best. It’s easy to use, and I cant even feel it when it’s in.
    If you have a problem with the more common contraceptives, ask your doctor about a diaphragm.

  23. hi- I would like to speak my mind about using the diaphragm. when I got fitted for the diaphragm my gynecologist told me that my pelvic area was just perfict for a milex diaphragm. while I had 2 children the were both by a C-section and that nothing was stretched by childbirth. when I put my diaphragm in me it just slips right in behind my pelvic bone completely covering my cervix. when my husband and I have sex sometimes his penis hits my diaphragm but he it feels good to him when this happens.i have absolutely not had any problems from using it. we plan to keep on using this method of birth control I go through menopause.

  24. oh my god. So glad I came across this post. I went off the pill at 27 because I started wondering if I was really me with all those hormones and chemical changes. I’m now 36, have 2 kids. We actually want more, but have very little money. The natural method and withdrawal have worked fine. I just try to be careful around ovulation. My husband is willing to get a vasectomy (which isn’t covered as birth control in the Affordable Care Act), but we’re just not quite ready to call it a day. I wanted a backup for around ovulation so I don’t wake up in a state of panic after a night of sex wondering what have I done!? Went to my midwife and got fitted for a diaphragm, which seems like a godsend – easy, spontaneous, cheap, durable, long-lasting and no hormones. I cannot find a pharmacy to fill this prescription, which is absolutely ridiculous! We are so willing to pump women full of hormones, with all these dangerous reactions, changing their body chemistry, and I cannot for the life of me get a piece of latex to use whenever I want. We talk about access to birth control and no where is this discussion taking place. Thank you!

  25. I love the idea of a hormoneless birth control method. I read that keeping the diaphragm in for over 24 hours can cause toxic shock, but has anyone left it in for around 14-15 hours and had a problem? (for night time and morning sex)

  26. Sarah Irlbeck says:

    Hey I have the exact same issue. My father died at 31 from a blood clot in his leg and the dr hesistated and refused to give me anything hormonal because of the blood clot issue. I actually researched all forms of birth control methods before I saw the doctor and found the diaphragm and saw it had no hormones so I mentioned it to the doctor and shes like oh wow! I haven’t heard that name in years I dont even know if we have one lol. She fitted me for it right there and whem I went to pick it up from the pharmacy they had to special order it cause they dont sell it. It is obvious that no one uses it anymore but geez I dont see why cause it seems like a great form of birth control thats safe hormone free and effective :) .

    • I am so disappointed. Went to my Dr. today for my annual. She did a refit measurement for a diaphragm. This has been my birth control choice on and off for 28 years. To my horror, the pharmacy called to say Ortho stopped manufacturing them. Called another pharmacy and they said the same. I have used the pill with awful side effects after my children were born and the copper IUD that left me anemic from the constant bleeding. All I want to do is make it safely through menopause with a trusted and reliable form of birth control. Can anyone recommend where their pharmacy located one?

    • Are you in the us? I can’t find ONE place to fill my diaphragm rx! Help! I’m so over BC pills. My hair has come out and I’m depressed all day. Got fitted for one but can’t find a place/store to get it. It’s easier to buy drugs

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