My Experiences with the Cervical Cap

Birth Control Review

Wife and mom shares her struggle to avoid hormonal contraceptives and pregnancy with the FemCap

My first experience with the cervical cap was after the birth of my second son. I had two babies within 12 months of each other, and my body needed a break from childbirth. I had decided some time ago that I wouldn't use the Pill any longer, due to side-effects, health concerns, and other personal reasons. I was looking for something effective but hormone-free.

Now, I do realize that there are many legitimate uses for oral contraceptives. If you read the promotional literature, you will discover that they cure everything from acne to PMS to cancer, but no matter how many health claims I come across, I hear the words of my sister ringing in my ears. "No one should take hormones, unless they have a medically-determined shortage or hormones or some other serious problem that requires it." Now, I don't listen to everything my sister says, but seeing as she has a Ph.D. and two masters degrees -- in specialties including neuroscience, genetic engineering, and biochemistry -- I pay attention when she talks about drugs. Did I mention she also has an M.B.A. and runs pharmaceutical trials at a German university? Well, you get my point.

I actually am a proponent of natural methods of fertility control. I like the fact that women can learn what is happening in their bodies and when, and then use that knowledge to plan or prevent pregnancy. (And I must admit, it is very cool to know exactly when you ovulate.) But I found it difficult to use the sympto-thermal method during the postpartum period. Successful use of the sympto-thermal method requires that a woman be able to detect cyclical patterns of fertility, and the murky postpartum-breastfeeding time obscures many of the signs of ovulation. It is common for women to stop menstruating while breastfeeding, and in fact my period was absent for almost a year after childbirth. Contrary to Western conventional thought, breastfeeding can be an effective contraceptive for women who nurse frequently and do not give their babies other foods. In developing nations, where children typically breastfeed until the age of two or later, breastfeeding is the primary method of contraception and child spacing. However, I knew I could not rely on breastfeeding alone, as my youngest son was conceived only three months after the birth of his older brother, all the while receiving his sustenance au natural. "Very unusual," the doctor had said when my pregnancy test came out positive. Unusual, indeed!

At that time, women in my situation were typically fitted for diaphragms, but with a mild allergy to spermicides, I felt a diaphragm would be less than optimal. The diaphragm is basically a large round latex membrane, designed for holding spermicide in place. It requires quite a bit of the pesticidal goo, smacked right against the cervix and inner wall of the vagina. This seemed like a recipe for discomfort and itching. After a little research, the cervical cap was perhaps a better alternative. The device is smaller, and the spermicide stays mostly in the dome of the device, which fits right over the cervix. At the time, the cap was a fairly new device, and according to the latest research, the failure rates were comparable to the diaphragm.

At my six week postpartum check up, I decided to ask my ob/gyn for a cervical cap. I was prescribed the Prentif Cap, a small tan thimble with a thick rim made of latex. With a little practice, I found it reasonably easy to insert, and it seemed to stay in place just fine. The spermicide remained in the cup and didn't escape into the vaginal canal. I used it without problems for about ten months. During that time, updated failure rates became available for the cervical cap. As I excitedly opened the latest version of Contraceptive Technology, I was stunned by what I read -- for women who have had children, the annual failure rate was 26% for perfect users and 32% for typical users. This meant that every year, one out of every four women using the cap would become pregnant, despite following all the directions for the device to a tee. Typical users, who might make an occasional mistake in using the device properly, would have a one in three chance of pregnancy. Unacceptable!

I ran back to by ob/gyn and explained my dilemma. Those odds were no good, and I wasn't going to use the cap anymore. She performed a vaginal exam and inspected the fit of my cap. "This isn't even covering your whole cervix," she said. "You need a larger size." She pulled out a bigger cap from a box and held it up for me to see. It seemed huge. I decided that I could work some better odds on my own. "Have you thought about the Pill?" the doctor asked. Of course, I had thought about it, and against it. I politely declined. My husband and I used a combination of condoms and natural family planning for the next few years with fairly reasonable success.

Sometime last year, the makers of the Prentif cervical cap closed shop in the US. When I was updating my women's health website, I came across some encouraging information about another type of cervical cap called the FemCap. The FemCap seemed like a good alternative to the Prentif cap as it is made of a durable, non-allergenic silicone instead of latex. It is shaped like a sailor hat, which permits spermicide to be placed on both sides of the cup. Nonetheless, it had some questionable failure rates, especially among women who had given birth. I contacted the manufacturers, located in California, and asked for more information.

I was sent a few articles and videos by email that made some impressive claims. Cap sizes were small, medium and large, fitted purely by obstetrical history. No doctor visit is required to select the right size. Why does obstetric history affect the fit and efficacy of the device? During pregnancy, the uterus expands to about twenty-four times its normal size. During childbirth, when the muscles of the uterus contract to force the baby out, the cervix stretches to about 4 inches (10 cm). The uterus never completely returns to its pre-pregnant size, and the opening of the cervix remains slightly changed in shape.

I had an opportunity to speak with the physician who researched and designed the device, Dr. Alfred Shihata. He acknowledged that an early version of the FemCap suffered from the same lack of efficacy among women who had given birth. He attributed this to weak vaginal muscles that were not able to effectively hold the cap snugly against the cervix. I wasn't sure I liked where this was going, but tried to focus on the scientific merits of the issue. In response to this problem, the cap was redesigned, and now accommodates women who've delivered children. If you wondered what my size was, you guessed it, I'm a large. I sometimes wonder if all the childbirth has taken its toll on my body in ways that might make my husband dissatisfied, but he reassuringly says that all is well.

Within a few days, my FemCap arrived in a priority envelope. It included the cap itself in a marbled blue case, an instruction booklet, and instructional DVDs. ("Those women in the study didn't even get to watch the DVD," Dr. Shihata had lamented.) Not only did I get to watch the DVD, my husband also gladly watched, no arm twisting required. (And then watched it again, I think.)

I went to see my ob/gyn to have the fit checked, just to be sure that I had gotten the size right. The first doctor I saw was a resident who didn't know much about the cap. "Uh, I think they stopped making those," he said. "But let me check with the nurse practitioner..." At this point I came to the uncomfortable realization that I probably knew fifty times more about birth control than the doctor. When he returned he informed me that the cervical cap was no longer available, "But would you like to try the Pill instead?" he asked. I politely declined and was out of there as fast as my legs would carry me. The whole thing left me annoyed and frustrated.

Dr. Shihata called me to see how my husband and I liked the cap. I told him that my husband was delighted with the device. "It's a hundred billion times better than condoms," he had said. Dr. Shihata seemed impressed. "A hundred billion is the biggest praise we have gotten yet," he mused. Once problem, however, is that I could sometimes feel that the cap is in place.

I also shared with him my disturbing experience with the ob/gyn. "Women send me email by the boat loads complaining of Pill-related side effects," I said, "which has only strengthened my resolve not to go back on hormones." And now I wanted support in trying to stay both hormone-free and baby-free only to met with ignorance and indifference. No wonder so many women end up on the Pill, suffering from side effects, with no idea where to go or what to do about it.

Dr. Shihata had another perspective. "One thing you have to remember is that doctors are very busy, and it's a lot quicker to write a prescription than to learn about a new birth control device." Another thing is that the pharmaceutical industry wines and dines doctors, constantly pushing their pills. The doctors in turn, push the pills on their patients.

Dr. Shihata had a good point. And it's not just pills, but rings, patches, and IUDs as well — all hormonal, all with side effects, all marketed by the pharmaceutical industry. In my Abnormal Psychology course, I typically spend a whole lecture helping students understand just how much of a patient's medical treatment is dictated by big pharma. Drug companies spend 15 billion dollars per year on physician marketing, which comes out to $10,000 per doctor. This may seem like a lot, but in fact in 2001, consumers spent 154.5 billion dollars on prescription drugs. The money spent on romancing doctors is just a calculated business investment. Research studies show that drug companies have the greatest influence on doctors' prescribing habits, ahead of medical consultants and patient request. A full seventy percent of family doctors regard drug reps as an efficient way to obtain information about new drugs. Only 17 percent of doctors use peer-reviewed journals, one of the best sources of unbiased information. It is true that many published studies are sponsored by drug companies, but at least this information is disclosed at the foot of the article. Interestingly, most doctors feel they are not influenced by the shark-like, sample-toting, free-lunch-providing pharmaceutical reps, but they do feel that other doctors (not nearly as savvy as themselves) probably are. In psychology, we call this a self-serving bias.

I reflected back on the long, induced labor that preceded birth of my youngest daughter. Just a few short hours later, at the peak of my disorientation and fatigue, an obstetrician I didn't recognize appeared like an apparition at the side of my bed. "I would like to start you on the mini-pill," she said. I politely declined, but the shadowy figure wouldn't stop. "It's a good choice for you and it won't decrease the volume of your breast milk." I couldn't understand what the doctor was doing there — and why wouldn't she go away? I was in no shape to fight with her, but I did know that the drugs in oral contraceptives also appear in the breast milk. Why didn't she share that nice little fact with me? Why was no one concerned about exposing a neonate to synthetic sex hormones? I sure was, but big pharma clearly was not, and the doctor had become their spokesperson. Prior to that point I thought it had all been a hallucination, but as I spoke to Dr. Shihata things were becoming clearer.

"I've got something for you to read," Dr. Shihata said. "I'm sending it by email. A new research article just came out in the journal of sexual research. They're now finding that the pill can cause a loss of libido." "That is not news," I said. "We have known this for some time..." "No, you see, the studies show that the loss of sex drive can be permanent. Even after discontinuing the pill."

Pretty shocking, yes, but also a mighty convenient excuse for the next time I wasn't in the mood. "Honey, remember those pills I took 15 years ago...?"

The next day I sent an email to my ob/gyn clinic expressing my concern about the misinformation I had received, and was put in touch with the clinic director, who offered to see me herself. I went back, and I shared my concerns about the fit of the cap and the intermittent crampy feeling I sometimes felt when the cap was in place. The doctor had done her homework. She had a copy of a recent article from a top contraceptive journal that surveyed women about their experiences with the FemCap. Although most liked it well enough, there was a sizable fraction that experienced some discomfort. Apparently in the process of reengineering the cap from the first to the second generation, it became more effective but less comfortable. Another part of the problem is that the doctor noted my uterus was flipped backwards in an unusual manner. "That could be contributing to the discomfort," she noted. Also she said that some women just have a very sensitive cervix. It did seem that that my cramps were worse at mid-cycle, when I am likely ovulating.

It had been six years since the birth of my youngest child. Was it possible that my cervix had shrunken back, closer to its original size? Could I get by with a medium cap? Would that possibly cut down on the cramping? "There's ample room around the outside of the cap," the doctor said. "I don't think I would go with a smaller size." Hmm, I sighed inwardly. "But if you like, I can prescribe an IUD," she continued. I politely declined.

I have been using the FemCap now for over a year, and it seems to work well. No surprise pregnancies as of yet. I have never been able to find an easy solution to my contraceptive needs, but for the time being, the FemCap works for me. Nonetheless, I cannot completely extricate myself from the clutches of the pharmaceutical industry. The spermicide that goes inside the cap is made by Ortho, one of the largest manufacturers of oral contraceptives. (And pesticides, I should mention.) So, even though I remain hormone-free, I toss another dollar into their coffers.

article by M. Williams

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