WOMEN &HEALTH

#1

If the Cap Fits....

By Linda Jane

The industry that brought us the Pill now offers contraceptive choices that women don't have to swallow. One new development involves shooting six capsules of progestin encased in silicone under the skin of a woman's forearm. An enthusiastic report in Medical World News this past February explains that this method provides the protection of 2,500 birth control pills (6 years' worth).. On a sober note, the implant's ,4 percent failure rate is somewhat offset by accompanying headaches, nausea, irregular bleeding, and bruising at the site of the implant.

In case you're still in a hurry to place an order with your doctor, you may have to wait. The FDA has yet to approve the implant-and the FDA can be pretty stringent when it wants to be.

One case in point is the cervical cap, a simple barrier device which fits over the cervix. Although the cap has none of the glamour of the high-technology implant, the FDA has targeted it as an "investigational" device and, thus, subject to tight control.

The cervical cap is not a new method of birth control. This small, thimble-shaped cap which works on a similar principle to the diaphragm, was actually invented before it. In 1837 Wilde, a German physician, wrote of midwives inserting caps at the time of delivery, and he himself prescribed them in his practice. He used caps made of rubber which he custom fit to the woman's cervix using a wax impression. In the 1860's a New York physician began to use them in his practice, but his work was stopped with the passage of the Comstock Laws, which sought to end all "vices" in the late 1870's. The diaphragm did not appear in the medical literature until 1882. In Germany in the 1920's, cervical caps outsold diaphragms

4 to 1.

Although the cervical cap continued to gain popularity in Europe, it did not catch on in the U.S.

CERVICAL CAP

DIAPHRAGM

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·FALLOPIAN TUBE OVARY

UTERUS CERVIX

One reason may have been the influence of two contraceptive pioneers in the 1920's and 1930's, Margaret Sanger and Marie Stopes. Stopes, Sanger's counterpart in England, developed her own cervical cap and prescribed it extensively in her clinic. Sanger, on the other hand, imported the "Dutch Cap" from Holland (today's diaphragm) which she promoted in her clinic in New York. Another possible reason was that the caps manufactured here were made of metal, plastic, or hard rubber and were reported to be difficult to insert. Most caps today are made of flexible rubber..

Whatever the reasons, the last of the U.S. cap manufacturers went out of business in the 1950's.

Page 6/What She Wants/October, 1981

Today the only company that manufactures cervical caps for contraceptive purposes is Lamberts Limited in England.

With the advent of the birth control pill and the IUD in the early 1960's, all forms of barrier methods declined in popularity. Use of the condom, for example, estimated at 26 percent of couples using birth control in 1955, declined to 18 percent in 1965. As the evidence of medical risks associated with both the newer types of contraceptives grew, however, many women began to rethink their contraceptive choices, and barrier methods took an upward turn.

As part of this trend, more women began to request the cervical cap. Its rebirth started in the late 1970's when a nurse practicitoner in New Hampshire, began prescribing it in her private practice. The New Hampshire Feminist Health Center asked her to help them fit women with cervical caps and also began to conduct research on its safety and effectiveness. More requests resulted from Barbara Seamen's book Women and the Crisis in Sex Hormones, which devoted an entire chapter to the cervical cap. By 1979 there were 100 clinics, health centers, and physicians providing caps in the U.S., and this figure doubled by 1980. It is estimated that between 10,000 and 15,000 women have requested the cap over the past three years.

It is not difficult to understand why women would take such an interest in the cervical cap. The cervical cap is simple, safe, and relatively effective. It has several advantages over the diaphragm. The diaphragm is designed to cover a large portion of the vagina, as well as the cervix, and stays in place by spring tension against the vaginal wall. The cervical cap, since it is designed to cover the cervix only, is deeper,and smaller in diameter, and makes a tighter fit due to the suction created when it is placed over the cervix. Both devises are designed to hold spermicide against the os, the opening to the uterus, although recent literature suggests that the cap, and even the diaphragm, may provide sufficient barriers when used without spermicide.

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Like the diaphragm, the cervical cap can be inserted by the woman. However, because it is placed higher up in the vagina, its insertion may be slightly more difficult, particularly if the woman has short fingers. Also, because it stays in place by suction, it may be more difficult to remove, particularly after being kept in place for several days.

The cap can be particularly useful for women who cannot, wear diaphragms due to various anatomical reasons. These include weak pelvic muscles, an

dispense caps. They're also criticized as being hard to insert and remove, but understand that much of this criticism comes from physicians, some of whom doubt that most women are capable of finding their cervixes. Also, some women complain that leaving the cap in place for longer time periods creates an unpleasant odor, but this problem can be avoided by washing the cap more often of adding a drop of chlorophyll to the inside of the cap before insertion.

Other criticisms-for example, that the cap may cause cervical erosion due to continued contact with the cervix, or that it prevents the free flow of cervical secretions which prevent infection-have not been confirmed. There is a possibility, however, that the cap may not fit properly and thus may become dislodged during intercourse. Most providers therefore suggest using another form of birth control in addition to the cap for the first couple of months until the woman is confident that her cap will stay in place.

Of course, in looking at the various forms of contraception, a prime consideration is usually its effectiveness. What makes the statistics difficult to inter-

PILL?

Nicole Hollander

pret, as with any barrier method, is that the cervical cap does require more effort than swallowing a pill or having an IUD sit in your womb, so it is more vulnerable to "improper use". But when woman are given sufficient information to judge the health risks of oral contraception and IUD's as opposed to barrier contraceptives, chances are many more of them will be "motivated" (as the medical literature is fond of saying) to make the extra effort.

Most of the literature contends that the cervical cap and diaphragm are comparable in effectiveness when used in conjunction with spermicide-in other words, from 80 percent to 98 percent effective. The failure rate for birth control pills ranges from less than 1 percent to 2 percent, and IUD's at less than 1 percent to 6 percent. The largest study of the cervical (continued on page 11)

unusually angled uterus, à short anterior vaginal Depo Dumped

wall, or a bulging of the bladder or rectal wall into the vagina. And it is also easier to fit, since the cervix comes in fewer shapes and sizes than the vagina (caps come in 4 basic sizes, diaphragms in 12 or more). A woman should not use a cap if she has cervical erosion or laceration or a very long, short, or irregularly shaped cervix.

Many experts agree that the cervical cap can be left in place longer than the diaphragm, although just how long is the subject of debate. The original caps used by Wilde were kept in place during the entire iń termenstrum (between periods), and some physicians still recommend this practice. Much of the literature, however, suggests that they be kept in place for at least 8-12 hours after intercourse and no longer than three to four days. Between use, the cap should be removed and washed with soap and water. Almost all the literature cautions against using the cervical cap as a sole means of birth control during a woman's period. The menstrual fluid can break the suction, and the cap may become dislodged.

In terms of disadvantages, probably the worst-problem is that the cap is hard to find. Due to a recent FDA ruling, only a few clinics in the U.S. can legally

(Hersay) A South African physician is charging the developed world with dumping the injectable contraceptive, Depo-Provera, on the Third World.

Doctor Nthato Motlana told The Nation that family planning agencies funded by the South African government are "administering shots to young black girls without even-asking their consent".

The U.S. Food and Drug Administration banned domestic use of the drug in 1978, due to evidence the substance causes cancer and birth defects. However, Upjohn Pharamaceutical Company continues to market the contraceptive abroad, and it is estimated that five million women in Asia, Latin America and Africa are still using it.

A ban on U.S. exports of Depo-Provera and similar drugs is not likely. A draft policy statement on U.S. exports obtained by The Washington Post last week indicates the federal government may soon be eliminating regulations governing the export of products considered too harmful for legal use in the

U.S.