Female barrier methods of contraception include caps, diaphragms and condoms. The contraceptive sponge is no longer available in the UK.
Caps and diaphragms form a physical barrier, preventing entrance of sperm to the cervix. They also provide a reservoir for spermicide.
Very few women in the UK use diaphragms, caps, or female condoms. Statistics published by the Health and Social Care Information Centre (HSCIC) in 2014 regarding methods prescribed by community contraceptive clinics at first contact suggest that in the 2013-2014 year 0.1% of women used female condoms.In this report diaphragms and caps do not have enough usage to make their own statistic, being part of the 2.4% "other methods" category, which also includes emergency contraception, the vaginal ring and natural methods.
Their popularity as forms of contraception has declined with the availability of more effective methods. However, they still offer options to those who are unable to use other forms through personal preference or contra-indications, or for those who desire a female-controlled form of contraception.
They are potentially suitable for use by most women, as they are non-hormonal forms of contraception. However, the relatively high failure rate should be taken into consideration.
Diaphragms are thin, dome-shaped devices made of latex or silicone and range in size between 55 mm and 100 mm.
Diaphragms should lie diagonally between the posterior fornix and behind the pubic bone. They come in three styles available on the NHS:
- Flat spring - these are firm and are suitable for women with normal vaginal musculature and particularly those with a shallow arch behind the symphysis. They are rubber-based. These are in the process of discontinuation in the UK.
- Coil spring - these are silicone-based and have a softer spring which may feel more comfortable. They are suitable for women with a normal pelvis and deep pelvic arch.
- Arcing spring - these fold at two points, making them easiest to insert. They are also silicone-based. They are useful for women with poor vaginal muscle tone or those with a retroverted uterus.
A newer one-size diaphragm, marketed as Caya®, made of silicone and featuring a polymer spring, is available online and over-the-counter in some places. It is available without the need for fitting as it only comes in one size. It was reviewed by the Faculty of Sexual and Reproductive Healthcare (FSRH) which advises it is better for women to obtain their diaphragm from a service which fits diaphragms.[2, 3]
Caps are smaller than diaphragms and sit directly over the cervix, held by suction. In the UK they tend to be reserved for women who have had problems with the diaphragm. The only cap which can be prescribed in the UK is the silicone FemCap®, which comes in sizes 22, 26 and 30 mm. It must be left in place for 6-8 hours after intercourse and may be left in place for up to 48 hours.
The only spermicide currently licensed for prescription in the UK is Gygel®, which contains 2% nonoxinol-9. Spermicide is not adequate contraception alone.
The use of spermicide is advocated with caps and diaphragms, although a 2003 Cochrane review failed to prove its contraceptive contribution.Spermicide use is not recommended with condoms.
Available as Femidom®.
This is a loose-fitting polyurethane sheath with two flexible polyurethane rings - one at either end. It sits in the vagina. At the closed end of the tube the ring is not fixed but helps make insertion easier. It also acts as an internal anchor. At the open end, the flexible ring lies outside the vagina. It is lubricated with non-spermicidal lubricant. No fitting is required.
Instructions for use
- Never re-use a female condom. Always check the expiry date.
- Take care not to damage with fingernails or jewellery when removing it from the packet.
- It may be inserted any time before sex but must always be in position before the penis touches the genital area.
- In a comfortable position - eg, squatting or one leg up on a chair - hold the closed end of the condom and squeeze the ring between the thumb and middle finger.
- Using the other hand to open the labia, push the ring as high into the vagina as possible.
- Place the middle finger into the open end of the condom and try to feel the inner ring. Push it high into the vagina.
- Make sure the outer ring is lying close to the vulva. It is advisable to guide the penis into the condom, to avoid slipping between condom and vagina.
- To remove the condom, twist the outer ring (to trap semen inside) and pull gently.
- With barrier methods, efficacy is largely user-dependent, the keys to success being good fitting, patient education and motivation.
- When used perfectly, in the first year of use:
- Around 6% of women using diaphragms will conceive.
- Around 20% of parous women using caps will conceive.
- Around 9% of nulliparous women using caps will conceive.
- Around 5% of women using the female condom will conceive.
- When used typically, in the first year of use:
- Around 16% of women using diaphragms will conceive.
- Around 32% of parous women using caps will conceive.
- Around 16% of nulliparous women using caps will conceive.
- Around 21% of women using the female condom will conceive.
- No serious side-effects.
- May be a useful choice where fertility is reduced (eg, breast-feeding, perimenopause).
- More independent of intercourse than condoms, allowing greater sexual spontaneity (caps and diaphragms).
- No loss of sensation (caps and diaphragms).
- Diaphragms and caps may be preferred to female condoms as female-controlled barrier methods, as there is less perceived interference with sexual pleasure.
- Less effective than other methods.
- Requires motivation and careful use.
- Requires some forward planning and confidence examining one's genitals.
- Must be used with spermicide which can make it messy and cause irritation or allergy.
- The female condom is noisy.
- Diaphragms and caps require fitting on at least an annual basis and education from a trained health professional.
- Little evidence of protection from sexually transmitted infections (STIs).
- May increase risk of urinary tract infections (UTIs) - mostly with diaphragms.
These are taken from the UK medical eligibility criteria (UKMEC) based on the World Health Organization (WHO) criteria. There are no absolute contra-indications (UKMEC category 4), and all conditions are UKMEC category 1 (no restriction) for female condoms. The following are UKMEC category 3 for diaphragms and caps, meaning usually the risk outweighs the benefits.
- The patient is known to have, or is at high risk of, HIV/AIDS. This is because there is evidence that repeated high-dose use of the spermicide nonoxynol-9 is associated with increased risk of genital lesions, which may increase the risk of acquiring HIV. (These are UKMEC 3 due to the risk associated with the spermicide and therefore the restriction applies to diaphragms and caps. However, the consistent and correct use of female condoms may reduce the risk of HIV transmission.)
- History of toxic shock syndrome.
- Latex allergy (consider a silicone device). These women can use a silicone diaphragm or cervical cap, or a polyurethane female condom.
- Spermicide allergy.
Additional cautions include:
- Anatomical constraints - inadequate retropubic ledge, or uterovaginal prolapse. However, cervical/vault caps may be possible. Also, markedly anteverted cervix or septate vagina, or severe obesity.
- Woman unable to insert or remove the device.
- Cervical cancer or cervical intraepithelial neoplasia (applies to caps only).
- Do not fit diaphragms/caps until six weeks postnatal to allow anatomy to be restored to normal.
Fitting and follow-up: caps and diaphragms
- Counsel fully to check the method is acceptable to the woman and that she is fully informed regarding risks/benefits, and provide reinforcing written information.
- Pelvic examination to assess suitability. The bowel and bladder should be emptied prior to fitting. Ideally, caps should be fitted mid-cycle.
- Select a size for a practice device (for a diaphragm, this should approximate the distance from behind the cervix to the pelvic arch).
- Start with the largest size that is comfortable. Check that the device does not fall out when the woman ambulates or performs a Valsalva manoeuvre.
- Teach the woman how to remove and insert the device. It is important that the woman should be aware of what her cervix feels like and how to check that the device fully covers the cervix when in the correct position.
- To insert a diaphragm, put your index finger on top of the diaphragm and squeeze it between your thumb and other fingers. Slide the diaphragm into the vagina in a downwards and posterior fashion. Some women find it easier to squat and others to lie down for insertion.
- To insert a cap, squeeze the sides of the cap together and hold between the thumb and first two fingers, allowing it to "suction" neatly over the cervix.
- The woman goes home with a practice device. She must be aware not to rely on it for contraception until after the second visit.
The woman should return with the device in situ to enable the positioning and size of the device to be checked. Any problems the woman has encountered fitting it should be fully explored.
Give specific instructions:
- Insert the device before sexual intercourse.
- Always use with spermicide.
- Use a total of 10 cm cream or jelly or one pessary (allowing 10 minutes to dissolve fully).
- Spermicide is only active for one to three hours, so if intercourse continues for longer than this time, or is repeated after this time, re-insert spermicide.
- Leave the device for at least six hours following sexual intercourse, but for no more than 30 hours (up to 48 hours for the cap).
- After removing the device, wash it in warm water and soap if required and dry before putting it away.
- Never use with oil-based products (eg, antifungal formulations, oestrogen creams, emulsifying ointment, Vaseline®, and massage oils), as these can cause the latex to decay more rapidly.
- Check for puckering and holes - if present, the device should be replaced urgently.
Follow-up should be on an annual basis since devices should be replaced at that interval (unless there is earlier evidence of damage):
- Any weight change of more than 3 kg should prompt a review.
- Fitting should also be checked after childbirth (at least six weeks postpartum), termination or miscarriage.
Reasons for women discontinuing use of diaphragms include:
- Difficulty with removal and insertion.
- Perception that leaving the diaphragm in the vagina after sex is "dirty".
- Desire for a more reliable form of contraception.
- Difficulty with insertion:
- Try a different size.
- Try an arching spring diaphragm.
- Try an applicator.
- Recurrent UTIs:
- Advise women to empty the bladder before and after intercourse.
- Try a smaller size or coil spring diaphragm.
- Change to a vault or cervical cap.
- Vaginal soreness:
- Check size.
- Treat any infection.
- Try an alternative spermicide.
- Consider rubber allergy.
- Partner feeling the device:
- Check size.
- Change to a coil spring device.
- Change to a vault or cervical cap.
Further reading and references
NHS contraceptive services: England Community Contraceptive Clinics 2013-14; Health and Social Care Information Centre (HSCIC), 30 October 2014
Discontinuation of Relfexions® flat spring diaphragm; Statement from the Faculty of Sexual and Reproductive Healthcare, January 2015
One size contraceptive diaphragm Caya® - New Product Review; Faculty of Sexual and Reproductive Healthcare, August 2014
British National Formulary (BNF); NICE Evidence Services (UK access only)
Barrier methods for contraception and STI prevention; Faculty of Sexual and Reproductive Healthcare (August 2012 - updated October 2015)
Contraception - barrier methods and spermicides; NICE CKS, June 2012 (UK access only)
Trussell J; Contraceptive failure in the United States, Contraception, 2011
UK Medical Eligibility Criteria for Contraceptive Use; Faculty of Sexual and Reproductive Healthcare (2009 - Revised May 2010)
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