A working vacation, training diaphragm fitters

A Milex diaphragm fitting set with five sizes 65mm – 85mm in 5mm increments

The Photo: Shows a CooperSurgical Milex contraceptive diaphragm fitting set and a demonstration unit to show patients how to insert it correctly. The silicon Milex wide seal diaphragm comes in two rim styles an arcing spring and the Omniflex which has a coil spring rim and comes in  8 diameter sizes, 60mm through 95mm in 5mm increments.

The Milex Arcing spring rim is similar to the (now discontinued) Ortho All-Flex in rim spring strength. However, unlike the All-Flex the Milex Arcing spring folds on two elbow hinges so must be compressed at two specific spots on the rim. The Omniflex can be folded by compressing it anywhere on the rim.

A wonderful training opportunity: Jack and Chris, our male Gyn, had been working for several months on a really great opportunity for the girls to meet some young male Gynecologists who are rising stars in their profession. The opportunity occurred because there was a Gyn conference in Inverness this past week which they were all attending. Diaphragm and cervical cap fitting is no longer being taught in med schools so since my wards and I would be in the area for the vernal equinox Chris offered to conduct a short course in cervical barrier fitting for five of the interested young doctors and got permission to hold it at Crag Abbey. 

He had cleared it with me first and I had gotten the required permissions for the girls to miss classes for several days to participate in a ‘medical seminar’. And of course anything that involves the vaginas of reproductive age women interests His Grace so the cervical barrier short course is underway and includes the silicone FemCap as well as the silicone Ortho All-Flex, the Milex wide seal arcing spring, the Milex wide seal Omniflex (coil spring) and the latex Reflexions flat spring devices and a new device that recently appeared on the market, the single size Caya contoured diaphragm that was designed to be used by women taking a traditional diaphragm in a range of the four most commonly prescribed sizes, 65mm through 80mm.  

How the seminar works: First there is a lecture on the particular device to be fitted (it’s positive and negative features and how it folds for insertion and removal techniques. Then there is a fitting demonstration with me as the patient and Chris as the fitter. Then the individual student Gyns take one of the girls or me as a fitting patient while Chris supervises the individual fitting processes; the pelvic exam (minus the PAP smear) to check for suitable pelvic anatomy needed for a correct fit and effective use of a cervical barrier; a pronounced post-pubic vault and a cervix that is not too anteverted or retroverted.

My women readers I’m sure are starting to squirm at the though of having six pelvic exams in a few days even if they don’t include PAP smears, but the girls and I are up for it and having lovely hunky knowledgeable men gently fondling our reproductive organs can be a huge turn-on which in itself is a problem when a Gyn is trying to fit the woman with a diaphragm of the correct size. That’s because if a patient becomes aroused while being fitted her vagina will tent (lengthen) so there is a good chance she will be prescribed a diaphragm that is too large with the attendant poor seal causing reduced effectiveness and discomfort that could cause a UTI.

To avoid that the Gyn should be professional and quick in his or her measurements and fitting and exchanging the correct size with a larger and smaller size so the patient can feel the difference with her fingers. That’s so if she gains or loses weight she can check with her fingers to verify her fit. A change in weight of +/-10 lbs and she should have her fit checked by a knowledgeable fitter. Usually a gain in weight requires a smaller size and a decrease in weight requires a larger size, but not always.

STI screening: Getting recent full STI panels on the five student Gyns and Emma wasn’t as difficult as I first feared. They were each able to supply a current and clean full STI panel as they had been told it was a requirement for participating in the course.

Esthetics: A few days before we left my wards and I went to Body Buffers for a full body waxing, everything but eyebrows and scalp hair. The dresser who travels with me also works at Body Buffers as an Esthetician for a few elite clients and we all go to her. She gives our pubes the smoothest and the least painful waxing of any Brazilian Esthetician I’ve ever used. My girls call her pubes waxing our ‘ballet bushes’, meaning there isn’t a trace of pubic hair anywhere on any of us when she is through. Women working in erotic dance and as escorts have long known that waxed pubes are the easiest to keep clean and provide the best line under very small gossamer costumes as well as a smooth surface for a man’s bush to rub against when we are entered from the front.

Emma: One of the student Gyns brought along his twenty-seven y/o wife, Emma, who is using the Symptothermal method of contraception (that measures basal body temp, cervical position and cervical fluid) backed by a fertility computer and condoms during her fertile days. I thought she might be a hindrance to the seminar. However, I found she and her husband are very broadminded about sex among friends. Too, she has been interested in trying cervical barriers in lieu of condoms and being fitted with CBs she was thrilled as much as the other girls to have the opportunity to enjoy intimate relations with each of the student Gyns. We all felt that sampling six new men known to be STI free and knowledgeable about female anatomy; the five student Gyns and Chris was a chance not to be missed.   

The girls, including Emma, spent half a day with each Gyn then moved to a different one, Chris making the sixth Gyn, and each gave his ‘patient’ road tests of their barriers so all six of us girls were able to have sex with each of the six men.  Jack had been called away to London on estate business so with Emma, my four wards and me that gave us a one-to-one ratio of women to men, ideal for a seminar of this nature that requires women circulating between partners so the Gyns can learn about how different women react and different barriers feel. Important knowledge when they will be counseling patients about their choice of a cervical barrier. Then we all move to the study fitting and trial of a different device. The cervical barriers being studied and fitted are: 1. Ortho All-Flex arcing spring – included because while manufacturer discontinued there are still so many in use. 2. The Milex Arcing spring and, 3. The silicone Omniflex, coil spring rim. 4. The latex Reflexions flat spring, 5.The Caya single size contoured rim and 6. The FemCap.  The seminar is going extremely well and is being enjoyed by all concerned as we get to sleep with a different man each night.

The last two days will be spent giving the student Gyns experience with Ballet-sex, dive-sex and under-thrusting coil spring and Caya diaphragms. Usually the last day(s) of a seminar are noted for the attendees disappearing, but that won’t be the case with this one because there is nowhere for them to go and no attending heterosexual male is going to miss two days of ballet-sex in the studio and dive-sex (in the Abbey’s heated pool) with lovely, young, experienced and very tight muscled girls. Jack had twelve sets of SCUBA gear with OTS Guardian FFMs, tanks and a portable air compressor for refilling tanks as well as a Divemaster laid on for our day of dive-sex training. I’m CD17 and all of us are luteal except Emma who is fertile and overdue to ovulate. She thinks it is due to the stress of being with so many new men, which is probably the case.

Coaching Emma: Since Emma would be having sex with her husband plus five new men repeatedly over in interval of four days and she wasn’t as sexually experienced as the rest of us girls I took her aside and taught her a bit about penetrative sex with multiple partners. Things like making sure she inserted the prefilled disposable (surface size 5ml or the 10ml for dive-sex prefilled applicators) of Dive Gel+ before her first encounter with each new man and to urinate before and immediately after sex to minimize the likelihood of UTIs an YIs from the different bacteria from so many men over such a short time and to check the placement of her diaphragm or cap immediately before and again immediately after each act of IC.  

Fortunately Emma took ballet in school and has continued adult pointe classes after her work as an office manager for an engineering Co. in London. She also routinely practices Kegels with one inch Pyrex Ben Wa balls and I found she is tightly muscled when I checked her pelvic anatomy to make sure she was physically suitable for the seminar.   It’s amazing how many Gyn and ER doctors’ marry sexually adventuresome women who take pointe and Emma is relatively good for someone taking only three ninety minute classes a week. Jack had previously alerted her husband about how the seminar was set up so she knew to bring practice clothes and pointe shoes (she wears Grishko 2007s) and we all take class in the tower studio that had been built for Cyndi where I have practiced for years.

I was fortunate and managed to catch her a few days before we arrived and discussed the desirability of having her pubes waxed, if for no other reason that there would be a lot of activity down there and even a tightly trimmed bush tends to get in the way with that much activity. She was already ahead of me and had booked a full body waxing.  I suggested that since she would be new to ballet-sex she might want to stop by a local dance shop, she went to Dancia International (the one in Drury Lane), to be fitted for hard shanked Gaynor Minden shoes for her introduction to ballet-sex. Otherwise she would have had to wear her Grishko 2007s which I think would have been very unpleasant for her. Even in hard shanked GMs I’m not sure how well her feet and calves will hold up during ballet-sex.

Looking a day or two ahead: The weather forecast for Inverness is for clear or partly cloudy through this Friday with the evening temps at or just above freezing and in the high 40s during the day. So we should have good weather for the start of our return home.

How diaphragms and FemCap are fitted

A current Milex wide seal diaphragm fitting set.

Being fitted for a diaphragm or cap: On another forum a friend asked “How does a woman get fitted for a diaphragm or cervical cap?” I’ve written a great deal about the delights and problems with wearing a contraceptive diaphragm or cap, but I can’t recall ever posting about how one is fitted so I thought I’d write about that now.

Tools: The fitter should use a diaphragm fitting set. Currently available sets used in the U.S. contain one diaphragm in each of the five most commonly prescribed sizes (65 – 85mm) and the sizes are standardized across manufacturers in 5mm increments. I use an old Milex fitting set because it has the most sizes, eight, from 60mm to 95mm and they are silicone. The most recent Milex fitting set is shown in photo accompanying this post. If a fitter tells you that s/he doesn’t need a fitting set to properly size your diaphragm (and sometimes we get a patient who has been told that) you should terminate the visit and go to someone who knows what they are doing.

The fitting: For this discussion I’m assuming that the patient’s vagina isn’t blocked by an inelastic hymen that would prevent proper fitting and possibly intercourse and that her pelvic anatomy; post-pubic vault and cervical aspect will permit the effective use of a diaphragm. A bimanual (the first two fingers of the hand) exam is performed before which the bladder and bowels should be emptied. During the exam the fitter determines the tone of the pelvic floor, the amount of relaxation (which determines if an arcing, coil or flat spring rim would be best) and the depth of the vagina.

The distance from the posterior fornix to the back of the pubic bone is estimated by inserting the two fingers of a gloved hand behind the posterior fornix then bringing the thumb knuckle to rest on the pubic symphysis then removing the fingers with the thumb still in place. The distance from the longest finger to the thumb knuckle joint establishes the approximate size. With the thumb still in place the closest diameter diaphragm is selected from the fitting set to cover that distance. That’s the starting point.

I first try that one and if it seems to fit well I’ll try one size larger and one size smaller and have the patient feel the difference in the distances between the anterior rim and the back of her pubic bone for each so she knows what the rim of a correctly sized diaphragm feels like when checking with her fingers. Then I’ll have her walk around with the correct diaphragm inserted to show her than when properly inserted she can’t feel it. After which I’ll show her how to insert it and let her insert and remove the device several times while I’m there to answer questions.

Ideally, a woman using a diaphragm should have a pronounced post-pubic vault so the rim can be tucked up behind the pubic bone out of the way of a thrusting penis. A woman with a shallow or no post-pubic vault is not a good candidate because the anterior rim may be easily hit by the woman’s partner. With a properly fitted D in the unaroused state the woman should just be able to insert a finger between her pubic bone and the rim with the pad against the back of her pubic bone and the nail against the anterior rim.

It’s important that the patient should be unaroused during her fitting. She needs the largest size she can comfortably wear when unaroused. If she becomes aroused during her fitting she may be fitted with a too large diaphragm since when aroused the vagina lengthens (tents). Or, in an attempt to compensate for her arousal a fitter may prescribe a size that is too small for the patient. This may explain why some fitters seem to be prescribing diaphragms that are too small. A too large diaphragm, in addition to being uncomfortable, will press on the urethra and restrict urine flow which can contribute to a UTI. So it’s necessary to be very professional and quick when fitting patients. Even so quite a few patients become at least partially aroused. A too small diaphragm can be difficult to place correctly, more easily under-thrust and difficult to remove.

A woman should insert her D when she is not aroused. If she inserts when aroused, because the vagina lengthens, it becomes difficult and sometimes impossible to insert the D correctly. When that happens the posterior rim may go into the anterior fornix and the D is comfortable (as long as she remains aroused) while her cervix is unprotected. That’s why it is very important once the woman thinks her D is correctly placed, to feel with her fingers for her cervix under the dome. If she can’t feel her cervix under the dome it is not protecting her and she should remove and reinsert it.

The correct size of a diaphragm is weight sensitive. If a woman has a weight change of +/- 7 pounds she should have her fit checked. Typically (but not always) a weight gain will require a smaller size and a weight loss will require a larger size. A check to see if the diaphragm is too large, and pressing on the urethra, is to insert the diaphragm correctly when unaroused then urinate. There should be no restriction in urine flow. A properly sized and correctly inserted diaphragm is just as effective for parous women as nulliparous ones.

Cervical cap fitting: Currently there is only one cervical cap available in the U.S., FemCap. The maker’s website www.femcap.com has fitting guidelines that stress the woman’s obstetrical history as being the primary factor in determining which cap she should choose. However, it is a very good idea to have a proper fitting by an experienced FemCap fitter because aside from OB history some women’s cervix are larger or smaller than ‘the average’ (I take a 26mm when the guidelines say I should wear a 22mm) and some may have an anteverted or retroverted cervix that makes them a poor candidate for FemCap. That’s because the outer wall of the brim should seal flush against the vaginal wall and if the cervix is tipped significantly part of the brim won’t seal properly and will stick out where it will be hit by a thrusting penis. A properly fitting FemCap should seal flush against the vaginal wall and not touch the walls of the cervix. Contraceptive Technology says that FemCap is less effective for women who have given birth than for those who haven’t. FemCap can be purchased on-line w/o an Rx, but if you have purchased the wrong size or the cervix isn’t positioned to allow a good seal against the vaginal walls you are out the money for a device you can’t use.

Cervical caps like the Prentif cavity rim and Oves (now no longer generally available) were sized differently as they developed their seal by fitting tightly against the wall of the cervix, which meant that women who were good candidates for Prentif or Oves needed a smooth walled cervix with no flat spots, bumps or irregularities from birth trauma.