Combined Contraceptive Vaginal Ring Research Articles

Risks of Vaginally and Sexually Transmitted Infections With Contraceptive Vaginal Rings Compared to Oral Contraceptives [ID 2683643

INTRODUCTION: Use of combined contraceptive vaginal ring (CCVR) has been found to upregulate immune-related genes in the endocervix and mediators within the cervicovaginal fluid. Attachment and infection rates of certain pathogens within this tract can vary based on hormones within the local environment. Rat studies have shown treatment with estrogen prior to chlamydial infections was protective. Continued clinical safety analyses are critical as CCVR use continues to increase. We calculated risk of vaginal infections associated with CCVR compared to oral contraceptive pills (OCPs) via retrospective chart review. METHODS: De-identified data was collected from TriNetX. Using ICD-10 and RxNorm codes, study cohorts included women receiving etonogestrel and ethinyl estradiol CCVRs without segesterone, versus women on OCPs without vaginal hormones. Cohorts (n=30,796 each) were matched for age, race, and ethnicity. Statistical analysis within 1 year of CCVR placement used risk ratios (RRs); P<.05 was considered significant. RESULTS: Combined contraceptive vaginal rings showed increased risk of HSV-2 (RR 1.790; P<.0005), acute vaginitis (RR 1.722; P<.0005), subacute/chronic vaginitis (RR 1.904; P<.0005), subacute/chronic vulvitis (RR 1.969; P<.0005), acute vulvitis (RR 1.894; P<.0005), candidiasis (RR 1.464; P<.0005), trichomoniasis (RR 2.162; P<.0005), and pelvic inflammatory disease (PID) (RR 2.984; P<.0005). Combined contraceptive vaginal rings showed a decreased risk of chlamydia (RR 0.760; P=.047). There were no differences in risk of gonorrhea, syphilis, HIV, or anogenital warts between the CCVR and OCP cohorts CONCLUSION: In this chart review, women using CCVRs had increased risks for HSV-2, vaginitis, vulvitis, PID, trichomoniasis, and candidiasis and decreased risk of chlamydia compared to OCPs. Further study of local hormone delivery on the vaginal mucosa is warranted.

Risks of Infections With Contraceptive Vaginal Rings Compared to No Hormone Use [ID 2683646

INTRODUCTION: Alterations in the vaginal microbiome by hormones, foreign bodies, intercourse, etc., can affect the body’s susceptibility to infection. The effect of combined contraceptive vaginal rings (CCVRs) on the vaginal microbiome needs more study. We aim to explore the outcomes of CCVRs on vaginal health and infection risk when compared to women without hormone use to better understand the effect of these devices. METHODS: De-identified data were collected from TriNetX. Using ICD-10 and RXNorm codes, populations were selected for women receiving etonogestrel and ethinyl estradiol CCVR without segesterone use, versus sexually active women of reproductive age on no hormonal contraceptives. Cohorts were matched for age at index, race, and ethnicity. Statistical analysis within 1 year of CCVR placement using risk ratios (RRs); P<.05 was considered significant. RESULTS: Cohort sizes were 274,743 each. Combined contraceptive vaginal ring usage showed an increased risk of gonorrhea (RR 1.221; P=.012), HSV-2 (RR 1.229; P<.0005), acute vaginitis (RR 1.314; P<.0005), subacute/chronic vaginitis (RR 1.708; P<.0005), acute vulvitis (RR 1.708; P<.0005), subacute/chronic vulvitis (RR 1.722; P<.0005), pelvic inflammatory disease (RR 1.184; P<.0005), anogenital warts (RR 1.314; P<.0005), and candidiasis (RR 1.402; P<.0005) when compared to women receiving no hormonal contraception. Combined contraceptive vaginal ring showed significant decreased risk of chlamydia (RR 0.786; P<.0005), syphilis (RR 0.493; P<.0005), and HIV (RR 0.434; P<.0005). Trichomoniasis was statistically insignificant. CONCLUSION: Women on etonogestrel and ethinyl estradiol CCVRs have an increased risk of gonorrhea, HSV-2, vaginitis, vulvitis, PID, anogenital warts, and candidiasis, with a decreased risk of chlamydia, syphilis, and HIV when compared to women receiving no hormonal contraception. Further investigation could be useful in developing multipurpose prevention technologies.

Indian women should be encouraged to use combined contraceptive vaginal ring

This article is to spread awareness among Indian women regarding vaginal contraceptive ring use. Since the introduction of hormonal contraceptives, combined oral pills (COCs) have become the method of choice for many women. Although COCs have improved significantly, they have got some disadvantages. This has prompted development of non-oral hormonal contraceptive methods. One of them is combined contraceptive vaginal ring (CCVR). Most studies found out that CCVR was associated with good cycle control and was not associated with vaginal or cervical abnormalities. Treatment related adverse effects like headache, leucorrhoea, nausea, etc and systemic side effects are minimal. Most women found the ring easy to insert, easy to remove and were satisfied with ring usage. So it can be concluded that CCVR is an effective contraceptive with good cycle control that is well tolerated. It is associated with high user and partner acceptability and minimal local and systemic effects. Therefore gynaecologists and policy makers should give more emphasis on its routine use.

The impact of combined contraceptive vaginal ring on vaginal environment: an observational, longitudinal study

Purpose To assess the relationship between combined contraceptive vaginal ring (CVR) and vaginal microbiome using 16S rRNA gene sequencing. Materials and methods We enrolled 20 women for 8 weeks in an open-label study using CVR (NuvaRing®) that delivered 15 mcg ethinylestradiol and 120 mcg etonogestrel daily. The vaginal microbiome was assessed at baseline and after 2 months by sequencing the 16S rRNA genes amplified from the total genomic DNA isolated from the sample. Results Bacterial distribution richness and equity did not significantly change after 2 months, and the dominant bacterial strain was Lactobacillus crispatus. Only one woman with a history of vestibulodynia and recurrent vulvovaginitis showed an increase in bacterial biodiversity, with a switch to the relative abundance of anaerobic bacteria. Conclusions Our results suggest that CVR does not adversely affect the composition and structure of the vaginal microbiome. However, special care should be taken in patients with a history of vestibulodynia and/or recurrent vulvovaginal infections.

Hormonal Contraceptive Use and Association with Thromboembolism in Women with Sickle Cell Disease

Introduction Women with sickle cell disease (SCD) require broad access to highly effective contraceptive methods due to high rates of unplanned pregnancy and adverse maternal and fetal outcomes. Combined (estrogen-containing) hormonal contraception carries a known risk of thromboembolism (TE) in the general population, and women with SCD have higher baseline risk of TE, thus use of these agents in women with SCD may further increase that risk. The paucity of safety data on hormonal contraceptive use in women with SCD limits the ability of providers and patients to make informed decisions. Objectives This study aims to use population-level administrative claims data of publicly insured women with SCD in the United States (US) to assess patterns of hormonal contraception use and evaluate risk of TE during the first year of use. We hypothesized that TE rates are higher in women prescribed combined hormonal contraceptives (CHC) as compared to women prescribed progestin-only contraceptives (POC). Methods We obtained data using the Centers for Medicare and Medicaid Services Analytic eXtract (CMS MAX) from 2006-2018. Study population included females of reproductive age (12-44 years) with >3 ICD-9 or ICD-10 codes consistent with SCD. Women had to have ≥12 months of continuous enrollment with at least 6 months of data as 'washout period' prior to enrollment period. A new prescription for hormonal contraception was identified using national drug codes in pharmaceutical claims or ICD-9 or 10 procedure codes. CHC included the combined oral contraceptive pill (OCP), transdermal patch, and vaginal ring. POC included the progestin-only pill, depot medroxyprogesterone acetate (DMPA) injection, intrauterine device (IUD) and subdermal implant. TE was defined as the presence of ≥2 ICD-9 or ICD-10 codes for venous TE (deep vein thrombosis (DVT) or pulmonary embolism (PE)) or arterial TE (stroke or myocardial infarction (MI)). Arterial TE was also required to have an associated inpatient admission. Women were included in the analysis for 12 months after contraception initiation, or censored in the event of either contraceptive switch, pregnancy or abortion, or TE occurrence. Data were summarized descriptively and TE incidence rates were calculated as events per 1,000 person-years. Results We identified a total of 41,012 reproductive-aged women with SCD enrolled in CMS MAX, of whom 22.6% (n=9,261) had received ≥1 new prescription for hormonal contraception. Among women with new contraceptive use, 58.5% (n=5,420) initiated CHC and 41.5% (n=3,841) initiated POC. Median age at the start of contraception was 22.3 years (range: 12.0-43.9) and median age at the start of CHC and POC were 22.1 and 22.7 years respectively. Among CHC users, 84.6% (n=4,584) of women were prescribed the combined OCP, 7.7% (n=419) the transdermal patch, and 7.7% (n=417) the vaginal ring. For POC users, DMPA was prescribed to 72.3% (n=2,777), progestin-only pills to 21.2% (n=816), IUD to 4.2% (n=163) and subdermal implant to 2.2% (n=85) of women. A total of 141 (1.5%) new contraceptive users with SCD were identified to have a TE during the follow-up period. The median time from contraception initiation to TE diagnosis was 183 days (IQR: 82-244). The most common TE event was PE (46.1%) followed by DVT (41.8%), stroke (6.4%), and MI (2.1%); 3.5% of women had multiple TE events. TE rate was 16.4 events per 1,000 person-years in CHC users, and the TE event rate was 17.0 events per 1,000 person-years in POC users (p=0.84). Rates of TE did not differ between the two most commonly used methods in each group, the combined OCP (15.5 events per 1,000 person-years ) and DMPA (17.7 events per 1,000 person-years) (p=0.48). Conclusion Our work provides population-level data regarding contraceptive practices for women with SCD in the US. We found that CHC was more frequently prescribed than POC, and identified low rates of long-acting reversible contraception use. The most frequently prescribed agents were the combined OCP and the DMPA injection. TE rates after initiation of the combined OCP and DMPA did not differ. Although limited by the retrospective study design and use of administrative claims data, this study suggests a similar safety profile for CHC and POC in women with SCD with respect to risk of TE.

Systems Analysis Reveals Contraceptive-Induced Alteration of Cervicovaginal Gene Expression in a Randomized Trial.

Hormonal contraceptives (HCs) are vital in managing the reproductive health of women. However, HC usage has been linked to perturbations in cervicovaginal immunity and increased risk of sexually transmitted infections. Here, we evaluated the impact of three HCs on the cervicovaginal environment using high-throughput transcriptomics. From 2015 to 2017, 130 adolescent females aged 15–19 years were enrolled into a substudy of UChoose, a single-site, open-label randomized, crossover trial (NCT02404038) and randomized to injectable norethisterone–enanthate (Net-En), combined oral contraceptives (COC), or etonorgesterol/ethinyl–estradiol–combined contraceptive vaginal ring (CCVR). Cervicovaginal samples were collected after 16 weeks of randomized HC use and analyzed by RNA-Seq, 16S rRNA gene sequencing, and Luminex analysis. Participants in the CCVR arm had a significant elevation of transcriptional networks driven by IL-6, IL-1, and NFKB, and lower expression of genes supporting epithelial barrier integrity. An integrated multivariate analysis demonstrated that networks of microbial dysbiosis and inflammation best discriminated the CCVR arm from the other contraceptive groups, while genes involved in epithelial cell differentiation were predictive of the Net-En and COC arms. Collectively, these data from a randomized trial represent the most comprehensive “omics” analyses of the cervicovaginal response to HCs and provide important mechanistic guidelines for the provision of HCs in sub-Saharan Africa.

Hormonal contraception alters vaginal microbiota and cytokines in South African adolescents in a randomized trial

Young women in sub-Saharan Africa are disproportionally affected by HIV infection and unintended pregnancies. However, hormonal contraceptive (HC) use may influence HIV risk through changes in genital tract microbiota and inflammatory cytokines. To investigate this, 130 HIV negative adolescent females aged 15–19 years were enrolled into a substudy of UChoose, an open-label randomized crossover study (NCT02404038), comparing acceptability and contraceptive product preference as a proxy for HIV prevention delivery methods. Participants were randomized to injectable norethisterone enanthate (Net-En), combined oral contraceptives (COC) or etonorgesterol/ethinyl estradiol combined contraceptive vaginal ring (CCVR) for 16 weeks, then crossed over to another HC for 16 weeks. Cervicovaginal samples were collected at baseline, crossover and exit for characterization of the microbiota and measurement of cytokine levels; primary endpoints were cervical T cell activation, vaginal microbial diversity and cytokine concentrations. Adolescents randomized to COCs had lower vaginal microbial diversity and relative abundance of HIV risk-associated taxa compared to Net-En or CCVR. Cervicovaginal inflammatory cytokine concentrations were significantly higher in adolescents randomized to CCVR compared to COC and Net-En. This suggests that COC use may induce an optimal vaginal ecosystem by decreasing bacterial diversity and inflammatory taxa, while CCVR use is associated with genital inflammation.

Safety, efficacy and quality of life of the novel vaginal contraceptive ring containing etonogestrel/ethinylestradiol 11.0/3.474 mg after 3 years of "real life" experience.

Combined contraceptive vaginal rings (CVR) are increasingly appreciated due to several beneficial properties like avoidance of the hepatic first-pass effect, a comparatively low dosage of hormones and comfortable use. A further development of the widely used CVR releasing 0.12 mg etonogestrel (ETO) and 0.015 mg ethinylestradiol (EE) per 24 hours has been marketed since 2017. The 11.00/3.474 mg ETO/EE CVR Ornibel® is bioequivalent to the former product but differs in its polymer composition leading to improved stability. Here, results from recent studies on the novel CVR Ornibel® are reviewed including clinical trials on bleeding profile, acceptability, sexual function and other quality of life (QoL) parameters as well as in vitro studies on microbial adhesion to the CVR and the influence of ring rupture on hormone release. Findings are complemented with new data on contraceptive efficacy and safety of the new CVR that were assessed during 3 years of real-life experience.

Hormonal contraception and risk of STIs and bacterial vaginosis in South African adolescents: secondary analysis of a randomised trial

ObjectivesYoung women in sub-Saharan Africa are at high risk of STIs and unintended pregnancies, yet hormonal contraceptive (HC) use may affect STI risk. We compared the influence of three HCs...

Are the Effects of Oral and Vaginal Contraceptives on Bone Formation in Young Women Mediated via the Growth Hormone-IGF-I Axis?

Purpose: Combined hormonal contraceptive therapy has been associated with negative bone mineral density outcomes that may be route-dependent [i.e., combined oral contraception (COC) vs. contraceptive vaginal ring (CVR)] and involve the hepatic growth hormone (GH)/insulin-like growth factor-I (IGF-I) axis. The objective of the pilot study was to assess the impact of route of contraceptive administration on IGF-I and procollagen type I N-terminal propeptide (PINP) responses to an IGF-I Generation Test. We hypothesized that the peak rise in IGF-I and PINP concentration and area under the curve (AUC) would be attenuated following COC, but not CVR, use.Methods: Healthy, premenopausal women not taking hormonal contraception were recruited. Women were enrolled in the control group (n = 8) or randomly assigned to COC (n = 8) or CVR (n = 8) for two contraceptive cycles. IGF-I Generation Tests were used as a probe to stimulate IGF-I release and were completed during the pre-intervention and intervention phases. Serum IGF-I and PINP were measured during both IGF-I Generation Tests. The study was registered at ClinicalTrials.gov (NCT02367833).Results: Compared to the pre-intervention phase, peak IGF-I concentration in response to the IGF-I Generation Test in the intervention phase was suppressed in the COC group (p < 0.001), but not the CVR or Control groups (p > 0.090). Additionally, compared to the pre-intervention phase, PINP AUC during the intervention phase was suppressed in both COC and CVR groups (p < 0.001), while no difference was observed in the control group (p = 0.980).Conclusion: These data suggest that changes in recombinant human GH-stimulated hepatic IGF-I synthesis in response to combined hormonal contraception (CHC) use are dependent on route of CHC administration, while the influence on PINP is route-independent. Future research is needed to expand these results with larger randomized control trials in all age ranges of women who utilize hormonal contraception.Clinical Trial Registration: www.ClinicalTrials.gov registration NCT02367833.

Impact of Hormonal Contraceptives on Cervical T-helper 17 Phenotype and Function in Adolescents: Results from a Randomized, Crossover Study Comparing Long-acting Injectable Norethisterone Oenanthate (NET-EN), Combined Oral Contraceptive Pills, and Combined Contraceptive Vaginal Rings.

BackgroundAdolescents in sub-Saharan Africa are at risk for human immunodeficiency virus (HIV) infection and unintended pregnancies. Observational studies suggest that injectable hormonal contraceptives (HCs) increase the HIV risk, although their effects on genital inflammation, particularly HIV-susceptible T-helper 17 (Th17) cells, are unknown. In a randomized crossover study, the effect of injectable norethisterone oenanthate (NET-EN), combined contraceptive vaginal rings (CCVR; NuvaRing), and combined oral contraceptive pills (COCPs) on cervical Th17 cells and cytokines were compared.MethodsAdolescents (n = 130; 15–19 years) were randomly assigned 1:1:1 to NET-EN, CCVR, or COCPs for 16 weeks, then subsequently crossed over to another HC for 16 weeks. Estrogen, follicular stimulating hormone (FSH), and luteinizing hormone (LH) levels were measured. Chemokine receptor 5 (CCR5), human leukocyte antigen (HLA) DR isotope, and cluster of differentiation 38 (CD38) expression by cervical cytobrush-derived CD4+ T cells was assessed by fluorescence-activated cell sorting. Th17 cells were defined as CCR6+ and CCR10-. Cervicovaginal Th17-related cytokines were measured by Luminex.ResultsCCVR use for the first 16 weeks was associated with reduced Th17 frequencies and lower FSH and LH concentrations, as compared to NET-EN and COCPs, with FSH concentrations and Th17 frequencies correlating significantly. However, Th17-related cytokine concentrations (interleukin [IL]-21, IL-1β, tumor necrosis factor–α, interferon-γ) and CCR5, HLA-DR, CD38, and Th17 frequencies were significantly higher in CCVR than NET-EN and COCP. At crossover, CCVR users changing to COCPs or NET-EN did not resolve activation or cytokines, although switching from COCP to CCVRs increased cytokine concentrations.ConclusionsCCVR use altered endogenous hormone levels and associated cervical Th17 cell frequencies to a greater extent than use of NET-EN or COCPs, although Th17 cells were more activated and Th17-related cytokine concentrations were elevated. While CCVRs may impact the HIV risk by regulating Th17 numbers, increased activation and inflammation may balance any risk gains.

Comprehensive overview of the recently FDA-approved contraceptive vaginal ring releasing segesterone acetate and ethinylestradiol: A new year-long, patient controlled, reversible birth control method

ABSTRACTIntroduction: This is an overview of the recently FDA-approved silicone elastomer combined hormonal contraceptive vaginal ring (CVR), which is used cyclically for up to 1 year, eliminating resupply challenges. This ring requires no refrigeration, simplifying the supply chain. Developed by the Population Council, this CVR will soon be marketed in the United States as Annovera™ by TherapeuticsMD.Areas Covered: The composition of the elastomer ring and the chemical, pharmacokinetic and pharmacodynamic properties of both hormonal components are discussed. Results of the clinical trials of its efficacy, tolerability, safety, and acceptability follow. Finally, subanalyses from the clinical trials are presented to guide clinicians in counseling potential users.Expert Opinion: This CVR introduces a new progestin – segesterone acetate (SA) – that has no androgenic or estrogenic action in vitro or in vivo, but has the highest anti-ovulatory potential of all available progestins. SA is paired with EE in an intravaginal elastomer ring, that is used cyclically (21 days in place/7 days removed) to provide 12 months (13 cycles) of contraception. This once-a-month, self-applied CVR offers a convenient, rapidly reversible, year-long contraception with efficacy and side effect profiles similar to other combined hormonal methods, for women with BMI < 29 kg/m2.

Effect of exogenous estrogens and progestogens on the course of migraine during reproductive age: a consensus statement by the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESCRH)

We systematically reviewed data about the effect of exogenous estrogens and progestogens on the course of migraine during reproductive age. Thereafter a consensus procedure among international experts was undertaken to develop statements to support clinical decision making, in terms of possible effects on migraine course of exogenous estrogens and progestogens and on possible treatment of headache associated with the use or with the withdrawal of hormones. Overall, quality of current evidence is low. Recommendations are provided for all the compounds with available evidence including the conventional 21/7 combined hormonal contraception, the desogestrel only oral pill, combined oral contraceptives with shortened pill-free interval, combined oral contraceptives with estradiol supplementation during the pill-free interval, extended regimen of combined hormonal contraceptive with pill or patch, combined hormonal contraceptive vaginal ring, transdermal estradiol supplementation with gel, transdermal estradiol supplementation with patch, subcutaneous estrogen implant with cyclical oral progestogen. As the quality of available data is poor, further research is needed on this topic to improve the knowledge about the use of estrogens and progestogens in women with migraine. There is a need for better management of headaches related to the use of hormones or their withdrawal.

Retinal vein occlusion associated with combined hormonal contraceptive vaginal ring use.

Retinal vein occlusion associated with combined hormonal contraceptive vaginal ring use.

Efficacy and side-effects profile of the ethinylestradiol and etonogestrel contraceptive vaginal ring: a systematic review and meta-analysis

Objective: To assess the efficacy and tolerability (side-effects profile), and compliance of the combined contraceptive vaginal ring (CCVR) compared with combined oral hormonal contraceptives (COC). Data sources: The PubMed, Embase, POPLINE, Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, ClinicalTrials.gov, Clinical Trials Registry Platform (ICTRP) and CINAHL databases were searched. Methods of study selection: Electronic databases were searched for randomised clinical trials comparing the CCVR with COC with a duration of at least 3 months between 01 December and 15 December 2015. The primary outcome was efficacy. The secondary outcomes were compliance, absence of withdrawal bleeding, breakthrough bleeding, nausea and headache. Heterogeneity was assessed using I 2 statistic and Cochran's Q statistic. Results were expressed as odds ratios (OR) with 95% confidence intervals (CIs) using random-effects models or fixed-effects models depending on the heterogeneity. Results: 4368 records were identified, 2844 of which were removed after duplicates and 1524 records were screened. Of these, 1503 were excluded and 21 full text articles were assessed for eligibility. After removing another 7 articles, 14 records were finally included in the qualitative and quantitative analysis. The results show a trend to higher efficacy for the CCVR in preventing pregnancy (Peto OR: 0.52 [95% CI: 0.26–1.04]) and a significantly lower presence of nausea (Peto OR: 0.66 [95% CI: 0.46–0.93]). More cycles were compliant in the CCVR group (Peto OR: 1.22 [95% CI: 1.12–1.32]) and fewer women reported breakthrough bleeding (Peto OR: 0.68 [95% CI: 0.51–0.91]). Conclusions: Our findings demonstrate that the CCVR is as effective and tolerable as the COC but with a better bleeding profile.

Prevalence of combined contraceptive vaginal rings in Norway.

Little is known about vaginal ring (VR) prescribers and user patterns in Norway and internationally. With data from the Norwegian Prescription Database, we explore user and prescriber characteristics of women initiating VR use. In a cross-sectional study design, we analyzed 47127 first-time VR users from 1 January 2006 to 31 December 2012. Follow up ended on 30 June 2013. We applied strict definitions for switching from any other hormonal contraceptive before and at the end of VR use. All analyses were performed using SPSS, with chi-squared test, t-test, and survival analysis. At study end, the prevalent use of VR reached 10 per 1000 women of fertile age, which amounted to 3% of all hormonal contraceptive use. The number of first-time VR users increased from 2006 to 2008 only among women under the age of 20. Nearly three out of four new users discontinued after 3months. Physicians without specialist status and general practitioners accounted for over 70% of the prescriptions, whereas gynecologists accounted for 17% of the prescriptions. Gynecologists were significant prescribers of VR to women aged 35 or more. Gynecologists are important providers of VR to first-time users above 30years of age. When prescribing VR to first-time users, it is important to discuss the need for contraception in a longer time perspective. Authorizing public health nurses/midwives as VR prescribers to teenagers, from 1 March 2006, may explain the relative increase in VR usage at a younger age.

The Combined Contraceptive Vaginal Ring: an Update

The combined contraceptive vaginal ring releases 120 μg of etonogestrel and 15 μg of ethinylestradiol per day for at least a 3-week period. It is as effective as combined oral contraceptive pills with similar side effects but better cycle control. The ring is not associated with weight gain and may have many non-contraceptive benefits including a positive effect on sexual function, dysmenorrhea, premenstrual syndrome, and heavy menstrual bleeding. Contraindications are the same as for combined oral contraceptives, and serious complications are rare. The risk of venous thromboembolism with the ring is comparable with that of combined oral contraceptives. The rate of acceptability of the ring is high, and most women, including adolescents, can use the ring.

Randomized comparison of bleeding patterns in women using a combined contraceptive vaginal ring or a low-dose combined oral contraceptive on a menstrually signaled regimen

ObjectivesTo compare bleeding patterns for 12months continuous use of a contraceptive ring [contraceptive vaginal ring (CVR)] and pill [combined oral contraceptive (COC)] on a menstrually signaled regimen and the effectiveness of 4days “treatment withdrawal” to stop bleeding. Study designWomen, 66 to each group, were randomized to continuous use of a CVR (15mcg ethinyl estradiol/150mcg etonogestrel) or a low-dose pill (20mcg ethinyl estradiol/100mcg levonorgestrel) for 360days on a menstrually signaled regimen. Bleeding/spotting days, daily use of ring or pill, was recorded. Endpoint was the total number of bleeding/spotting days for each method over four 90-day reference periods (RP) plus the analysis of bleeding patterns using modified World Health Organization criteria. ResultsThere was a reduction in the mean (±S.D.) number of bleeding/spotting days from RP1 (CVR 14.2±10; pill 16.6±10.9) to RP4 (CVR 8.8±9.6; pill 8.8±9.1). Fifteen percent of CVR and 4% COC users experienced amenorrhea or infrequent bleeding throughout the study. Amenorrhea increased over time (RP1 vs. RP4: CVR 10% vs. 21% and COC 2% vs. 30%). Compliance with the menstrually signaled regimen was poor. Ceasing hormones for 4days stopped a bleeding episode within 5days in the majority of episodes and many stopped spontaneously. ConclusionBleeding patterns with continuous use of the CVR and COC are similar and improve over 1year of use. The unpredictability, but short duration, of bleeding episodes should be stressed during counseling. ImplicationThis information for clinicians and women about breakthrough bleeding patterns with use of a CVR or combined pill over 12months using a menstrually signaled regimen will give women an indication of what to expect with continuous use.

Evaluating the efficacy and safety of a progestin- and estrogen-releasing ethylene vinyl acetate copolymer contraceptive vaginal ring

Introduction: Multiple studies confirm the safety and efficacy of the combined ethinyl estradiol (EE) and etonogestrel contraceptive vaginal ring (NuvaRing®). Advantages of continuous drug delivery through the vagina compared to oral administration include stable levels of contraceptive steroids without the need for daily drug administration. Although the combined contraceptive vaginal ring (CCVR) avoids the problem of missed pills, clinical data do not support greater efficacy. Vaginal administration avoids first-pass hepatic effects; however, EE is a potent inducer of hepatic globulins regardless of the route of administration. Consequently, thromboembolic risk during CCVR use is similar to that with combined oral contraceptives. Some epidemiologic and database studies suggest that the risk of thromboembolism is increased among users of the CCVR compared to levonorgestrel-containing combined pills.Areas covered: This review examined the available literature for level 1 and level 2 evidence of the CCVR and its associated efficacy and safety. Studies are presented in table format with significant findings and conclusions described.Expert opinion: A prospective study with 33,235 woman-years of exposure and with greater ability to control for covariates did not demonstrate an elevation of risk. The safety profile of the CCVR appears to be the same as with other combined hormonal contraceptives.

Desogestrel‐only contraceptive pill versus sequential contraceptive vaginal ring in the treatment of rectovaginal endometriosis infiltrating the rectum: a prospective open‐label comparative study

To compare the efficacy of two hormonal therapies in treating symptoms caused by bowel endometriosis. Patient preference study. University hospital. A total of 143 women with rectovaginal endometriosis infiltrating the rectum. This study was performed between January 2008 and June 2011. Patients were treated with a desogestrel-only contraceptive pill or with the sequential combined contraceptive vaginal ring for 12months. The primary endpoint of the study was the rate of satisfied patients at 12-month follow up. The changes in symptoms and in the volume of the nodules were secondary endpoints. At 12-month follow up, the rate of satisfied patients was higher in the group treated with the desogestrel-only contraceptive pill than in the group treated with the sequential combined contraceptive vaginal ring (p=0.004). When only changes in gastrointestinal symptoms were considered, 50% of patients treated with the desogestrel-only contraceptive pill and 31.3% of those treated with the sequential combined contraceptive vaginal ring were satisfied (p=0.037). The reduction in the volume of the nodules, the percentages of patients who discontinued the therapy after the completion of the study and of those who decided to undergo surgery were similar between the two groups. Both hormonal therapies are efficacious in treating symptoms caused by rectovaginal endometriosis infiltrating the rectum. Patient satisfaction is higher with the desogestrel-only pill than with a vaginal ring.