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The Cervical Cap: An Alternative Contraceptive
principles and practice The Cervical Cap: An Alternative Contraceptive PA TRICIA ANN CANA VAN, RN, MS, a n d CLA UDIA ANN LE WIS, RN, MS
Recentjndings on health hazards of oral contraceptives and intrauterine devices have prompted American women to seek alternative forms ofbirth control which are both safe and efective. The cervical cap may provide a desired alternative and is relatively inexpensive. Types of caps are described below, with nursing guidelinesfor use andjtting
For years, men and women have perienced by women using oral conattempted to control their fertility traceptives or intrauterine device^.^ with varying degrees of success. The The cervical cap, widely used in concerns of consumers over hor- Europe since the nineteenth century, monal and intrusive contraceptive has recently resurfaced in the United methods is demonstrated by their S t a t e s as a n a l t e r n a t i v e concurrently increased usage of barrier traceptive choice. T h e cap elimimethods.‘.’ The majority of barrier nates many of the above-mentioned devices in use today have the same consumer complaints. Advantages pitfalls as when they were first mar- a n d disadvantages a r e listed in keted. Health care providers have Table 1. frequently received complaints from A review of the literature indiaphragm users about the device’s dicates that the cervical cap is rarely inherent disruptiveness, expense, discussed a s a m e a n s of conand messiness. Users of foam and traception in t h e U n i t e d States condoms have expressed similar dis- today. A 1953 study reported a rate satisfaction. The literature abounds of 7.6 pregnancies per 100 women with statistics on the side effects ex- years of use for the cavity rim cap.6
Pregnancy prevention with the cervical cap depends on the population studied. Statistics have been quoted giving the cap an effectiveness range as high as 98% and as low as 85%.’ Reasons for these discrepancies in figures include differences in age, educational background, motivation, and socioeconomic It is difficult to evaluate these studies since they place all vaginal barrier devices, including diaphragms, in one category when discussing effectiveness rates. The cervical cap is a small barrier device which can be filled with spermicidal agent and placed over the cervix. Protocol at the authors’ practice recommends that women fill the caps two-thirds full with a contraceptive agent containing 5% nonoxynol-9 spermicide. The cap can be left in place for a maximum of seven consecutive days without
-
Table 1. Advantages and Disadvantages of the Cervical Cap ADVANTAGES
RATIONALE
1. Does not require daily client involvement
1 . Cap can be left in place up to 7 days provided it retains contraceptive cream 2. Teaching the woman requires that she identify her cervix 3. Cap is applied to the exterior of the cervix 4. Nothing is required of either the woman or her partner at this time 5. No spermicidal creams or jellies in the vagina
2. Woman learns more about her body
3. Nonhormonal and noninvasive 4. Convenient for coitus and foreplay
5. Oral sex more enjoyable than with other barrier methods
DISADVANTAGES 1 . Not all women can be safely fitted at present 2. Not manufactured in USA 3. Lack of knowledgeable health care providers 4. Time it takes to teach this method ranges from 30-90 minutes 5. Usage depends on individual female’s anatomy
July/August 1981JOGN Nursing 0090-03 1 1/81/07 15-0271$00.65
RATIONALE 1. Depends on the angle, shape, and size of cervix 2. May not be cost effective since it is expensive to import 3. Few are aware of the cervical cap and fewer can fit them correctly 4. Depends on many variables: woman’s comfort with her own body and sexuality, her manual dexterity, and her motivation 5. Short fingers and long vaginas make it very difficult for some women to use the cap
27 1
UTERUS
UTERUS
DUMAS CA P COVERING CERVIX
CAVITY-RIM CAP COVERING CERVIX
IJTERUS
V I M U L Z CAP COVERING CERVIX
VAGINA VAGINA
VAGINA
Figure 1. Dumas@cap
Figure 2. Cavity-rim cap
Figure 3. Vimule@cap
further attention provided the cap r e t a i n s its spermicide. T h e c a p s h o u l d b e r e m o v e d w h e n menstruation begins.
snugly into the vaginal fornices covering the length of the cervix.
exam. 2) T h e nurse must carefully check around the cap to search for gaps between the rim of the cap and the exterior of the cervix. 3) The nurse should be able to press in the dome of the cap, displacing the air, causing the dome to indent. 4) The nurse should attempt manually to displace the cap off the cervix, and if displacement occurs, the woman will not be given the cap. It must be emphasized that these guidelines are not foolproof. Client concerns about cervical caps include odor, misplacement during insertion, displacement during coitus, and partner’s discomfort. C a p odors are probably caused either by vaginal infections or by a combination of the cap’s rubber, the spermicidal agent, and normal vaginal flora and secretions. Client error in cap placement is rare in the authors’ experience. T h e extensive learning program, in which clients participate, helps to eliminate this c o n c e r n . C a p d i s p l a c e m e n t is equally rare because of the time spent by the practitioner in accurately fitting the client and making certain the woman is capable of correctly placing the cap snugly over her cervix.
Types of Caps C u r r e n t l y , t h e r e a r e no contraceptive caps manufactured in the United States. However, there are several types of cervical caps available from Europe. (The caps discussed below a r e available from Lamberts (Dalston) Ltd., Queensbridge Road, London, England: approximate price, $1 1 .OO.) T h e D u m a s @ c a p ( F i g . 1 ) is shaped like a half-squeezed lime and fits across the vaginal vault like a small diaphragm, thereby covering the cervix. T h e cap, composed of rubber and sized from 50 to 75 mm, can be used only if it accommodates the cervix within its shallow dome to fit snugly across the upper vagina. T h e soft, rubber cavity-rim cap (Fig. 2) is used by the majority of clients in the authors’ practice. This cap, which fits snugly over the cervix, resembles a thimble with a hollow, raised rim, and forms a suction between the cervix and the cap’s interior. It is available in four sizes: 22 mm, 25 mm, 28 mm, and 31 mm. T h e Vimule@ cap (Fig. 3) has a deep dome to accommodate a longer cervix. T h e rim flanges out to seal against the vaginal fornices. Sizes are numbered from 1 to 3, and the correct size will allow the cap to fit
Assessing Cap Candidates Matching a cap to a woman depends on multiple factors related to the angle, shape, and size of her cervix. Careful attention to the anatomy of the cervix is essential when fitting a woman for a cap. An assessm e h f the angle at which the cervix enters the vagina is crucial. If the cap’s rim can be touched by the penis during intercourse, then the potential for cap displacement is greatly increased. T h e length of the cervix must also be assessed. If the cervix is exceptionally long or short, it may be impossible to create a suction between the cervix a n d the cap’s interior. T h e Dumas cap cannot be easily fitted to a short cervix nor can the cavity-rim cap. If the anterior or posterior lips of the cervix are not aligned, cap suction may be hindered. This criterion is especially important with the cavity-rim cap. Obviously, with the limited types a n d sizes of caps from which to choose, not every cervix can be adequately covered, thus, some women cannot use the cap. It is not possible to assign or predict cap size according to pregnancy history. T h e authors perform four steps when assessing a woman’s candidacy for the cervical cap: 1) T h e angle of the cap, once placed on the cervix, should be assessed by digital
Summary The cervical cap is a convenient, inexpensive, nonhormonal and noninvasive contraceptive method. This method has potential for better ef-
fectiveness if custom-fit caps are manufactured. As more health care providers become knowledgeable in the use of the cap, more women will become aware of this contraceptive method as an alternative to oral contraceptives and intrauterine devices. Research is needed to document the most accurate method of cervical cap fitting and the effectiveness rate of the cervical cap. Nurse practitioners who counsel patients and fit them for caps are in the perfect position to start doing this research. Acknowledgments The authors wish to thank James P. Koch, MD, and Mary B. Foxon, R N , M S , a n d extend a special thanks to Denise M. Hutchinson, RN, for the illustrations.
References
tions: The control of fertility. TAMA, October 25, 1965, p 232 ,
1. Tietz, Lehfeldt, Liebman: The effectiveness of the cervical cap as a contraceptive method. Am J Obstet Gynecol, October 1953, pp 904-990 2. Atkinson L, et al.: Prospects for improved contraception. Fam Plann Perspect 12: 174, July/August 1978 3. Experts air pill and IUD problems. Contraceptive Tech Update 1(4):52 4. Rosenberg L, et al.: Oral contraceptive use in relation to nonfatal myocardial infarction. Am J Epidiol 1:59-65, 1980 5. Dickey R P , Berger GS: Post-pill amenorrhea, Controversies in Contraception. Edited by K Moghissi, 1977 6 Ramaswamey S, Smith T: Practical Contraception. Philadelphia, George F. Stickley Company, 1977, p 92 7 Committee on Human Reproduction of the American Medical Associa-
I
Address for correspondence: Patricia Canavan, RN, 40 Van Wart Path, Newton, MA 02159.
Patricia Canavan received her B S N from the University of Masschusetts and her M S from Boston College-Harvard. Working in a private practice in Brookline, Massachusetts, Ms. Canavan is a member of A N A and Sigma Theta Tau. Claudia Lewis attended the Universip of Connecticut ( B S N ) and Boston College-Harvard ( M S ) . M s Lewis is a member of NAACOG, ANA, A A R N P , and Sigma Theta Tau, and she is working in Ob/Gyn at an H M O In southern New Hampshire.
RESEARCH The Department of Nursing of The Johns Hopkins Hospital will hold “Nursing Research Day” on October 5, 1981, in Baltimore, Maryland. For further details contact Dr. Margaret R. Dear, The Johns Hopkins Hospital, Dept. of Staff Education, #693, 624 North Broadway, Baltimore, MD 21 205, (301) 955-5363.
Recentjndings on health hazards of oral contraceptives and intrauterine devices have prompted American women to seek alternative forms ofbirth control which are both safe and efective. The cervical cap may provide a desired alternative and is relatively inexpensive. Types of caps are described below, with nursing guidelinesfor use andjtting
For years, men and women have perienced by women using oral conattempted to control their fertility traceptives or intrauterine device^.^ with varying degrees of success. The The cervical cap, widely used in concerns of consumers over hor- Europe since the nineteenth century, monal and intrusive contraceptive has recently resurfaced in the United methods is demonstrated by their S t a t e s as a n a l t e r n a t i v e concurrently increased usage of barrier traceptive choice. T h e cap elimimethods.‘.’ The majority of barrier nates many of the above-mentioned devices in use today have the same consumer complaints. Advantages pitfalls as when they were first mar- a n d disadvantages a r e listed in keted. Health care providers have Table 1. frequently received complaints from A review of the literature indiaphragm users about the device’s dicates that the cervical cap is rarely inherent disruptiveness, expense, discussed a s a m e a n s of conand messiness. Users of foam and traception in t h e U n i t e d States condoms have expressed similar dis- today. A 1953 study reported a rate satisfaction. The literature abounds of 7.6 pregnancies per 100 women with statistics on the side effects ex- years of use for the cavity rim cap.6
Pregnancy prevention with the cervical cap depends on the population studied. Statistics have been quoted giving the cap an effectiveness range as high as 98% and as low as 85%.’ Reasons for these discrepancies in figures include differences in age, educational background, motivation, and socioeconomic It is difficult to evaluate these studies since they place all vaginal barrier devices, including diaphragms, in one category when discussing effectiveness rates. The cervical cap is a small barrier device which can be filled with spermicidal agent and placed over the cervix. Protocol at the authors’ practice recommends that women fill the caps two-thirds full with a contraceptive agent containing 5% nonoxynol-9 spermicide. The cap can be left in place for a maximum of seven consecutive days without
-
Table 1. Advantages and Disadvantages of the Cervical Cap ADVANTAGES
RATIONALE
1. Does not require daily client involvement
1 . Cap can be left in place up to 7 days provided it retains contraceptive cream 2. Teaching the woman requires that she identify her cervix 3. Cap is applied to the exterior of the cervix 4. Nothing is required of either the woman or her partner at this time 5. No spermicidal creams or jellies in the vagina
2. Woman learns more about her body
3. Nonhormonal and noninvasive 4. Convenient for coitus and foreplay
5. Oral sex more enjoyable than with other barrier methods
DISADVANTAGES 1 . Not all women can be safely fitted at present 2. Not manufactured in USA 3. Lack of knowledgeable health care providers 4. Time it takes to teach this method ranges from 30-90 minutes 5. Usage depends on individual female’s anatomy
July/August 1981JOGN Nursing 0090-03 1 1/81/07 15-0271$00.65
RATIONALE 1. Depends on the angle, shape, and size of cervix 2. May not be cost effective since it is expensive to import 3. Few are aware of the cervical cap and fewer can fit them correctly 4. Depends on many variables: woman’s comfort with her own body and sexuality, her manual dexterity, and her motivation 5. Short fingers and long vaginas make it very difficult for some women to use the cap
27 1
UTERUS
UTERUS
DUMAS CA P COVERING CERVIX
CAVITY-RIM CAP COVERING CERVIX
IJTERUS
V I M U L Z CAP COVERING CERVIX
VAGINA VAGINA
VAGINA
Figure 1. Dumas@cap
Figure 2. Cavity-rim cap
Figure 3. Vimule@cap
further attention provided the cap r e t a i n s its spermicide. T h e c a p s h o u l d b e r e m o v e d w h e n menstruation begins.
snugly into the vaginal fornices covering the length of the cervix.
exam. 2) T h e nurse must carefully check around the cap to search for gaps between the rim of the cap and the exterior of the cervix. 3) The nurse should be able to press in the dome of the cap, displacing the air, causing the dome to indent. 4) The nurse should attempt manually to displace the cap off the cervix, and if displacement occurs, the woman will not be given the cap. It must be emphasized that these guidelines are not foolproof. Client concerns about cervical caps include odor, misplacement during insertion, displacement during coitus, and partner’s discomfort. C a p odors are probably caused either by vaginal infections or by a combination of the cap’s rubber, the spermicidal agent, and normal vaginal flora and secretions. Client error in cap placement is rare in the authors’ experience. T h e extensive learning program, in which clients participate, helps to eliminate this c o n c e r n . C a p d i s p l a c e m e n t is equally rare because of the time spent by the practitioner in accurately fitting the client and making certain the woman is capable of correctly placing the cap snugly over her cervix.
Types of Caps C u r r e n t l y , t h e r e a r e no contraceptive caps manufactured in the United States. However, there are several types of cervical caps available from Europe. (The caps discussed below a r e available from Lamberts (Dalston) Ltd., Queensbridge Road, London, England: approximate price, $1 1 .OO.) T h e D u m a s @ c a p ( F i g . 1 ) is shaped like a half-squeezed lime and fits across the vaginal vault like a small diaphragm, thereby covering the cervix. T h e cap, composed of rubber and sized from 50 to 75 mm, can be used only if it accommodates the cervix within its shallow dome to fit snugly across the upper vagina. T h e soft, rubber cavity-rim cap (Fig. 2) is used by the majority of clients in the authors’ practice. This cap, which fits snugly over the cervix, resembles a thimble with a hollow, raised rim, and forms a suction between the cervix and the cap’s interior. It is available in four sizes: 22 mm, 25 mm, 28 mm, and 31 mm. T h e Vimule@ cap (Fig. 3) has a deep dome to accommodate a longer cervix. T h e rim flanges out to seal against the vaginal fornices. Sizes are numbered from 1 to 3, and the correct size will allow the cap to fit
Assessing Cap Candidates Matching a cap to a woman depends on multiple factors related to the angle, shape, and size of her cervix. Careful attention to the anatomy of the cervix is essential when fitting a woman for a cap. An assessm e h f the angle at which the cervix enters the vagina is crucial. If the cap’s rim can be touched by the penis during intercourse, then the potential for cap displacement is greatly increased. T h e length of the cervix must also be assessed. If the cervix is exceptionally long or short, it may be impossible to create a suction between the cervix a n d the cap’s interior. T h e Dumas cap cannot be easily fitted to a short cervix nor can the cavity-rim cap. If the anterior or posterior lips of the cervix are not aligned, cap suction may be hindered. This criterion is especially important with the cavity-rim cap. Obviously, with the limited types a n d sizes of caps from which to choose, not every cervix can be adequately covered, thus, some women cannot use the cap. It is not possible to assign or predict cap size according to pregnancy history. T h e authors perform four steps when assessing a woman’s candidacy for the cervical cap: 1) T h e angle of the cap, once placed on the cervix, should be assessed by digital
Summary The cervical cap is a convenient, inexpensive, nonhormonal and noninvasive contraceptive method. This method has potential for better ef-
fectiveness if custom-fit caps are manufactured. As more health care providers become knowledgeable in the use of the cap, more women will become aware of this contraceptive method as an alternative to oral contraceptives and intrauterine devices. Research is needed to document the most accurate method of cervical cap fitting and the effectiveness rate of the cervical cap. Nurse practitioners who counsel patients and fit them for caps are in the perfect position to start doing this research. Acknowledgments The authors wish to thank James P. Koch, MD, and Mary B. Foxon, R N , M S , a n d extend a special thanks to Denise M. Hutchinson, RN, for the illustrations.
References
tions: The control of fertility. TAMA, October 25, 1965, p 232 ,
1. Tietz, Lehfeldt, Liebman: The effectiveness of the cervical cap as a contraceptive method. Am J Obstet Gynecol, October 1953, pp 904-990 2. Atkinson L, et al.: Prospects for improved contraception. Fam Plann Perspect 12: 174, July/August 1978 3. Experts air pill and IUD problems. Contraceptive Tech Update 1(4):52 4. Rosenberg L, et al.: Oral contraceptive use in relation to nonfatal myocardial infarction. Am J Epidiol 1:59-65, 1980 5. Dickey R P , Berger GS: Post-pill amenorrhea, Controversies in Contraception. Edited by K Moghissi, 1977 6 Ramaswamey S, Smith T: Practical Contraception. Philadelphia, George F. Stickley Company, 1977, p 92 7 Committee on Human Reproduction of the American Medical Associa-
I
Address for correspondence: Patricia Canavan, RN, 40 Van Wart Path, Newton, MA 02159.
Patricia Canavan received her B S N from the University of Masschusetts and her M S from Boston College-Harvard. Working in a private practice in Brookline, Massachusetts, Ms. Canavan is a member of A N A and Sigma Theta Tau. Claudia Lewis attended the Universip of Connecticut ( B S N ) and Boston College-Harvard ( M S ) . M s Lewis is a member of NAACOG, ANA, A A R N P , and Sigma Theta Tau, and she is working in Ob/Gyn at an H M O In southern New Hampshire.
RESEARCH The Department of Nursing of The Johns Hopkins Hospital will hold “Nursing Research Day” on October 5, 1981, in Baltimore, Maryland. For further details contact Dr. Margaret R. Dear, The Johns Hopkins Hospital, Dept. of Staff Education, #693, 624 North Broadway, Baltimore, MD 21 205, (301) 955-5363.