Contraceptive Ring Research Articles

The effect of adverse information and positive promotion on women's preferences for prescribed contraceptive products

Recent rapid growth in the range of contraceptive products has given women more choice, but also adds complexity to the resultant decision of which product to choose. This paper uses a discrete choice experiment (DCE) to investigate the effect of adverse information and positive promotion on women's stated preferences for prescribed contraceptive products. In November 2007, 527 Australian women aged 18–49 years were recruited from an online panel. Each was randomly allocated to one of three information conditions. The control group only received basic information on contraceptive products. One treatment group also received adverse information on the risks of the combined oral pill. The other group received basic information and promotional material on the vaginal ring, newly introduced into Australia and on the transdermal patch, which is unavailable in Australia. Respondents completed 32 choice sets with 3 product options where each option was described by a product label: either combined pill, minipill, injection, implant, hormonal IUD, hormonal vaginal ring, hormonal transdermal patch or copper IUD; and by the attributes: effect on acne, effect on weight, frequency of administration, contraceptive effectiveness, doctor's recommendation, effect on periods and cost. Women's choices were analysed using a generalized multinomial logit model (G-MNL) and model estimates were used to predict product shares for each information condition. The predictions indicated that adverse information did not affect women's preferences for products relative to only receiving basic information. The promotional material increased women's preferences for the transdermal patch. Women in all groups had a low preference for the vaginal ring which was not improved by promotion. The findings highlight the need for researchers to pay attention to setting the context when conducting DCEs as this can significantly affect results.

A select issue in the postpartum period: contraception

A select issue in the postpartum period: contraception

Contraceptive vaginal ring effectiveness is maintained during 6 weeks of use: a prospective study of normal BMI and obese women

BackgroundA single study shows that contraceptive vaginal ring (CVR) use for up to 35 days in women with a normal body mass index (BMI) maintains serum hormone levels sufficient to suppress ovulation. This study is intended to confirm those results and to evaluate prolonged CVR use up to 42 days in both normal BMI and obese women. Study DesignTwenty women with a normal BMI and 20 obese women enrolled in a prospective open label clinical study of ethinyl estradiol (EE) and etonogestrel (ENG) pharmacokinetics during six weeks of use of a single CVR. Participants underwent twice-weekly evaluations to determine serum hormone concentrations, ovarian follicle development, endometrial thickness and bleeding patterns. ResultsThirty-seven women completed follow-up including eighteen women with a normal BMI and nineteen obese women. EE and ENG concentrations remained in therapeutic range for all women. Follicular development and endometrial proliferation were minimal. By the sixth week, 30% of participants reported spotting or bleeding. ConclusionsA single CVR used for 6 weeks demonstrates therapeutic serum levels of EE and ENG among women with normal and obese BMI. Women who forget to remove the CVR at day 21 may well have continued contraceptive protection during the next 3 weeks.

Transurethral placement of vaginal contraceptive device in a patient with neurogenic bladder: A case report and review of the literature

BackgroundThe NuvaRing is a vaginal contraceptive device that is placed and later removed by the user herself. Incorrect placement is a possible complication and seems an increased risk in patients with spinal cord abnormalities. CaseA 21-year-old female with a history of a T7-8 level spinal cord injury at birth and subsequent neurogenic bladder dysfunction and bladder augmentation presented with an 8 month history of suprapubic pain, right hip pain and urgency unresponsive to antibiotic therapy. Her symptoms began after her caretaker placed a NuvaRing contraceptive device, which subsequently was unable to be located. A thorough evaluation revealed a NuvaRing in the bladder. ConclusionForeign objects should be considered in patients with recurrent symptoms of cystitis which are unrelieved by antibiotic therapy. Intravaginal contraceptive rings should be used cautiously in patients with spinal cord abnormalities who require the assistance of caretakers for management of these devices.

Whatʼs Good and Bad About Contraceptive Products?

In the past decade, the range of contraceptives available has increased dramatically. There are limited data on the factors that determine women's choices on contraceptive alternatives or what factors providers consider most important when recommending contraceptive products to women. Our objectives were to compare women's (consumers') preferences and GPs' (providers') views in relation to existing and new contraceptive methods, and particularly to examine what factors increase the acceptability of different contraceptive products. A best-worst attribute stated-choice experiment was completed online. Participants (Australian women of reproductive age and Australian GPs) completed questions on 16 contraceptive profiles. 200 women of reproductive age were recruited through a commercial panel. GPs from all states of Australia were randomly sampled and approached by phone; 162 GPs agreed to participate. Participants chose the best and worst attribute levels of hypothetical but realistic prescribed contraceptive products. Best and worst choices were modelled using multinomial logit and product features were ranked from best to worst according to the size of model coefficients. The most attractive feature of the contraceptive products for both GPs and women consumers were an administration frequency of longer than 1 year and light or no bleeding. Women indicated that the hormonal vaginal ring was the least attractive mode of administration. Women and GPs agree that longer-acting methods with less bleeding are important features in preferred methods of contraception; however, women are also attracted to products involving less invasive modes of administration. While the vaginal ring may fill the niche in Australia for a relatively non-invasive, moderately long-acting and effective contraceptive, the results of this study indicate that GPs will need to promote the benefits of the vaginal ring to overcome negative perceptions about this method among women who may benefit from using it.

Emergency Contraception

Despite significant declines over the past 2 decades, the United States continues to have teen birth rates that are significantly higher than other industrialized nations. Use of emergency contraception can reduce the risk of pregnancy if used up to 120 hours after unprotected intercourse or contraceptive failure and is most effective if used in the first 24 hours. Indications for the use of emergency contraception include sexual assault, unprotected intercourse, condom breakage or slippage, and missed or late doses of hormonal contraceptives, including the oral contraceptive pill, contraceptive patch, contraceptive ring (ie, improper placement or loss/expulsion), and injectable contraception. Adolescents younger than 17 years must obtain a prescription from a physician to access emergency contraception in most states. In all states, both males and females 17 years or older can obtain emergency contraception without a prescription. Adolescents are more likely to use emergency contraception if it has been prescribed in advance of need. The aim of this updated policy statement is to (1) educate pediatricians and other physicians on available emergency contraceptive methods; (2) provide current data on safety, efficacy, and use of emergency contraception in teenagers; and (3) encourage routine counseling and advance emergency-contraception prescription as 1 part of a public health strategy to reduce teen pregnancy. This policy focuses on pharmacologic methods of emergency contraception used within 120 hours of unprotected or underprotected coitus for the prevention of unintended pregnancy. Emergency contraceptive medications include products labeled and dedicated for use as emergency contraception by the US Food and Drug Administration (levonorgestrel and ulipristal) and the "off-label" use of combination oral contraceptives.

Medical treatment of idiopathic heavy menstrual bleeding. What is new? An evidence based approach

Heavy menstrual bleeding (HMB) is an important health problem affecting up to 30 % of reproductive age women, interfering with their quality of life. Medical therapy, with the avoidance of unnecessary surgery, is an attractive option. To provide a comprehensive review of the current medical treatments available for idiopathic HMB and to focus on the newly introduced modalities. Furthermore, to provide a practical algorithm based on the best available evidence. A PubMed search was conducted looking for the different trials, reviews and various guidelines relating to medical treatment of idiopathic HMB. The most effective medical treatment for idiopathic HMB is the levonorgestrel-releasing intrauterine system. It provides a reliable long-term effect. Importantly, there is a growing scientific evidence for new modalities entailing; modified-release formulation of tranexamic acid, the new four-phasic estradiol valerate/dienogest contraceptive pills and combined contraceptive vaginal ring. Also, vaginal danazol has been tried. Maintenance of status quo, i.e., keeping first-line treatment of idiopathic HMB as medical treatment is an essential issue. Modified-release formulation of tranexamic acid, the new four-phasic contraceptive pills and contraceptive vaginal ring are recently added to the medical armamentarium for treatment of idiopathic HMB increasing its efficacy.

Extended and Continuous Combined Contraceptive Regimens for Menstrual Suppression

Many women have medical indications for menstrual suppression or a personal preference to reduce or eliminate monthly bleeding, which can be achieved with extended and continuous regimens of combined estrogen and progestin contraceptives. Combined contraceptives are traditionally administered in a 28-day cycle, with 21 days of a contraceptive pill, vaginal ring, or transdermal patch followed by a hormone-free interval that is usually 7 days. During the hormone-free interval, women either take a placebo pill or do not use their combined contraceptive method. Hormone-related symptoms are significantly worse during the hormone-free interval than the days when the contraceptive is used. Alterations of the standard 28-day cyclic regimen for menstrual suppression include decreasing the frequency of the hormone-free interval, thus extending the time between withdrawal bleeding episodes (extended use), and eliminating the hormone-free interval altogether (continuous use). This article reviews menstrual suppression indications and physiology. Research demonstrating that the effectiveness, safety, and side effects of oral, vaginal, and transdermal extended and continuous regimens are comparable to cyclic regimens is summarized. Findings from studies of women's and health care providers' attitudes toward menstrual suppression also are reviewed. Important topics to include in evidence-based counseling for extended and continuous combined contraceptive use are presented.

Contraceptive transdermal patches or vaginal rings were associated with increased venous thrombosis

Source Citation Lidegaard O, Nielsen LH, Skovlund CW, Lokkegaard E. Venous thrombosis in users of non-oral hormonal contraception: follow-up study, Denmark 2001-10. BMJ. 2012;344:e2990. 22577198

With Pills, Patches, Rings, and Shots: Who Still Uses Condoms? A Longitudinal Cohort Study

To describe women's condom use patterns over time and assess predictors of dual method use 12 months after initiating hormonal contraceptives. We conducted a prospective cohort study among women aged 15-24 years initiating oral contraceptive pills, patch, ring, or depot medroxyprogesterone and attending public family planning clinics. Participants completed questionnaires at baseline and 3, 6, and 12 months after enrollment. We used multivariable logistic regression to assess baseline factors associated with dual method use at 12 months among 1,194 women who were sexually active in the past 30 days. At baseline, 36% were condom users, and only 5% were dual method users. After initiation of a hormonal method, condom use decreased to 27% and remained relatively unchanged thereafter. Dual method use increased to a peak of 20% at 3 months but decreased over time. Women who were condom users at baseline had nearly twice the odds of being a dual method user at 12 months compared with nonusers (adjusted odds ratio [AOR]= 2.01, 95% CI: 1.28-3.14). Women who believed their main partner thought condoms were "very important," regardless of perceived sexually transmitted infection risk or participant's own views of condoms, had higher odds of dual method use (AOR= 2.89, 95% CI: 1.47-5.71). These results highlight a potential missed opportunity for family planning providers. Providers focus on helping women initiate hormonal methods, however, they may improve outcomes by giving greater attention to method continuation and contingency planning in the event of method discontinuation and to the role of the partner in family planning.

Long-acting reversible contraception for adolescents.

Teen pregnancy continues to plague the United States. This review will discuss long-acting reversible contraceptive (LARC) method use in teens, comprising intrauterine devices and subdermal implants. The American College of Obstetricians and Gynecologists along with the American Academy of Pediatrics, the Centers for Disease Control, and the World Health Organization have recognized the potential impact of LARC (comprising intrauterine contraception and subdermal implants) to reduce unintended pregnancies. They have affirmed the safety of such devices, and no effects on long-term fertility have been identified. Teen users of these methods have been shown to have high continuation and satisfaction rates. On the contrary, oral contraceptive pills, the patch, and the contraceptive vaginal ring have significantly higher contraceptive failure rates, and these rates are magnified in young women. LARC methods should be considered first-line options for teens seeking contraception.

Venous Thrombosis in Users of Non-Oral Hormonal Contraception: Follow-Up Study, Denmark 2001-10

Conclusion: Women who use transdermal patches or vaginal rings for contraception have approximately a six to seven times increased risk of venous thromboembolism (VTE) compared to women who do not use hormonal contraception. Summary: It is well known oral contraceptive agents increase the risk of VTE. There are, however, little to no data regarding the effects of methods other than pills to deliver hormonal contraceptive agents. Such methods include transdermal patches, subcutaneous implants, and vaginal rings. The authors used a historic national registry in a cohort study design to assess absolute and relative risk of VTE in Danish women using nonoral hormonal contraception. This national registry-based cohort study used four national registries from Denmark. All Danish nonpregnant women aged 15 to 49 years (n = 1,626,158), who were free of previous VTE or cancer, were followed up from 2001 to 2010. The main outcome measures were incidence rates of VTE in users of transdermal, vaginal, intrauterine, or subcutaneous hormonal contraception. Relative risk of venous thrombosis was compared with nonusers of hormonal contraception, and rate ratios of venous thrombosis in current users of nonoral products were compared with the standard reference of an oral contraceptive with levonorgestrel and estrogen (30-40 μg). A diagnosis of VTE was considered confirmed if there was at least 4 weeks of anticoagulation therapy after the initial VTE diagnosis. There were 5,287 first ever VTE events recorded within 9,429,128 women-years of observation. Of these VTE events, 3,434 were confirmed. The rate of confirmed VTE events was 2.1/10,000 years in nonusers of hormonal contraception. After adjustment for age, calendar year, and education, the relative risks and 95% confidence interval (95% CI) of confirmed VTE in users of transdermal combined contraceptive patches and vaginal ring compared with nonusers of hormonal contraception were 7.9 (3.5-17.7) and 6.5 (7.4-8.9), respectively. Corresponding incidence events per 10,000 exposure-years were 9.7 and 7.8 events. The relative risk (95% CI) was increased in women who used subcutaneous implants (1.4 [0.6-3.4]) but not in those who use the levonorgestrel intrauterine system (0.6 [0.4-0.8]). Compared with users of combined oral contraceptives containing levonorgestrel, the adjusted relative risk (95% CI) of VTE was 2.3 (1.0-5.2) in users of transdermal patches and 1.9 (1.3-2.7) in users of the vaginal ring. Comment: In the last paragraph of the discussion portion of this article the authors succinctly point out the implications of their study, “if the incidence rate of venous thrombosis in women using combined oral contraceptives containing levonorgestrel is 6 per 10,000 exposure years, that of the vaginal ring is 11 per 10,000 exposure years, and that of the transdermal patch is 14 per 10,000 exposure years, then 2000 women using the vaginal ring, and 1250 using the transdermal patch should shift to combined oral contraceptives with levonorgestrel to prevent 1 event of VTE in one year. A risk of 10 per 10,000 years implies a risk of VTE more than 1% over a 10 year user period. Therefore, women are generally advised to use combined oral contraceptives with levonorgestrel or norgestimate, rather than to use transdermal patches or vaginal rings.”

Increased impact of a contraceptive vaginal ring with ethinyl estradiol and nestorone on C-reactive protein

Objective & study designIn a parallel design, 23 and 22 healthy pre-menopausal women were randomly administered a contraceptive vaginal ring (CVR) delivering 150/15μg Nestorone®/ethinyl estradiol (EE) daily or an oral contraceptive (OC) containing levonorgestrel and EE (150/30μg) for three cycles, to compare the effects on C-reactive protein and other markers of inflammation. ANCOVA was performed with baseline values as covariate. ResultsThe CVR caused [estimate of difference (95% CI), 109% (16–275%)] higher levels of CRP than the OC, while no difference was observed for leukocyte 1% (−13/+17%) and monocyte counts 6% (−9/+23%). The greater increase in CRP was confined to CVR recipients exhibiting low pre-treatment CRP-levels, whereas no difference was observed in the increases for recipients in the highest tertile of pre-treatment CRP levels. ConclusionThe difference in CRP rise in CVR and OC users does not correspond with the effects on other markers of inflammation and is most likely due to a specific difference in the effect of ethinyl-estradiol combined with nestorone in cases with low CRP.

Effectiveness of Long-Acting Reversible Contraception

METHODS We designed a large prospective cohort study to promote the use of long-acting reversible contraceptive methods as a means of reducing unintended pregnancies in our region. Participants were provided with reversible contraception of their choice at no cost. We compared the rate of failure of long-acting reversible contraception (intrauterine devices [IUDs] and implants) with other commonly prescribed contraceptive methods (oral contraceptive pills, transdermal patch, contraceptive vaginal ring, and depot medroxyprogesterone acetate [DMPA] injection) in the overall cohort and in groups stratified according to age (less than 21 years of age vs. 21 years or older).

Pharmacokinetics of ethinyl estradiol and etonogestrel during extended use of a contraceptive vaginal ring

Pharmacokinetics of ethinyl estradiol and etonogestrel during extended use of a contraceptive vaginal ring

Removal of a Retained Chinese Contraceptive Ring: A Clinical Challenge!

Abstract Background: A challenging case of removal of a Chinese contraceptive device is presented. Case: A 41-year-old nulliparous Chinese woman presented to Ipswich Hospital for removal of an intrauterine device (IUD), inserted in 1998. Conclusions: Rapidly changing patient profiles mean that many practicing gynecologists may encounter a similar situation. (J GYNECOL SURG 28:312)

Oral, transdermal and vaginal combined contraceptives induce an increase in markers of chronic inflammation and impair insulin sensitivity in young healthy normal-weight women: a randomized study

What is the effect of alternative administration routes of combined contraceptives (CCs) on androgen secretion, chronic inflammation, glucose tolerance and lipid profile? The use of oral, transdermal and vaginal CCs impairs glucose tolerance and induces chronic inflammation. Oral CCs worsen insulin sensitivity and are associated with increased levels of circulating inflammatory markers, whereas the metabolic effects of transdermal and vaginal CCs have been reported to be minimal. This is the first study comparing three different administration routes of CCs on metabolic variables. This randomized (computer-generated) open-label 9-week follow-up study was conducted at the Oulu University Hospital, Finland. Fasting blood samples were collected at baseline and thereafter at 5 and 9 weeks of treatment, and serum levels of 17-hydroxyprogesterone, androstenedione, testosterone, C-reactive protein (CRP), sex hormone-binding globulin (SHBG), glucose, insulin, C-peptide, total, low-density lipoprotein and high-density lipoprotein cholesterol and triglycerides were measured. Oral glucose tolerance tests were performed and plasma levels of pentraxin 3 (PTX-3) were measured at 0 and 9 weeks. The randomization list, with an allocation ratio of 1:1:1 and block size of six, was computer generated and constructed by a pharmacist at the Oulu University Hospital. The research nurse controlled the randomization list and assigned participants to their groups at the first visit. Forty-two of 54 healthy women who entered the study used oral contraceptive pills (n = 13), transdermal contraceptive patches (n = 15) or contraceptive vaginal rings (n = 14) continuously for 9 weeks. Inclusion criteria were regular menstrual cycles, at least a 2-month washout as regards hormonal contraceptives and no medication. Serum levels of SHBG increased and consequently the free androgen index (FAI) decreased in all study groups from baseline to 9 weeks of treatment [FAI, oral: 1.3 (95% confidence interval, CI: 0.94; 1.62) to 0.40 (0.25; 0.54); transdermal: 1.2 (0.96; 1.4) to 0.36 (0.30; 0.43); vaginal: 1.6 (1.1; 2.1) to 0.43 (0.29; 0.58), P < 0.001 in all groups]. Insulin sensitivity was reduced at 9 weeks in all three groups according to the Matsuda index [oral: 7.3 (5.5; 9.0) to 5.6 (3.9; 7.3); transdermal: 9.1 (6.7; 11.4) to 6.6 (4.5; 8.8); vaginal: 7.7 (5.9; 9.5) to 5.4 (3.9; 7.0), P= 0.004-0.024]. Levels of HDL cholesterol, triglycerides and CRP rose in all three groups [CRP, oral: 0.70 (0.38; 1.0) to 5.4 (1.0; 9.9) mg/l; transdermal: 0.77 (0.45; 1.1) to 2.9 (1.4;4.4) mg/l; vaginal: 0.98 (0.52; 1.4) to 3.7 (-0.25; 7.7, a negative value due to skewed distribution to right) mg/l, P≤ 0.002 in all groups] and PTX-3 levels increased in the oral and transdermal study groups (P = 0.007 and P = 0.002). Although the long-term consequences of the present results remain undetermined, these findings emphasize the importance of monitoring glucose metabolism during the use of CCs, especially in women with known risks of type 2 diabetes or cardiovascular diseases. BIAS, LIMITATIONS, GENERALIZABILITY: The number of subjects was relatively low. Moreover, the 9-week exposure to CCs is too short to draw conclusions about the long-term health consequences. However, as the subjects were healthy, normal-weight young women, the possible alterations in the glucose and inflammatory profiles among women with known metabolic risks might be even greater. This work was supported by grants from the Academy of Finland, the Sigrid Jusélius Foundation, the Finnish Medical Foundation, the Research Foundation of Obstetrics and Gynecology, Oulu University Scholarship Foundation, the North Ostrobothnia Regional Fund of the Finnish Cultural Foundation, the Tyyni Tani Foundation of the University of Oulu and the Finnish-Norwegian Medical Foundation. No competing interests. NCT01087879.

Hormonal contraception and venous thromboembolism

New studies about the influence of hormonal contraception on the risk of venous thromboembolism (VTE) have been published. To evaluate new epidemiological data and to propose clinical consequences. A literature survey. Studies assessing the risk of specific types of hormonal contraception were evaluated, compared and set into a clinical perspective. The majority of newer studies have demonstrated a threefold increased risk of VTE in current users of medium- and low-dose combined oral contraceptives (COCs) with norethisterone, levonorgestrel (LNG) or norgestimate compared with non-users. The same studies have demonstrated a sixfold increased risk of VTE in users of combined pills with desogestrel, gestodene, drospirenone or cyproteroneacetate, and in users of the contraceptive vaginal ring, compared with non-users. The rate ratio of VTE between users of COCs with newer progestogens compared with users of COCs with LNG was 1.5-2.8 in seven studies and 1.0 in two studies. Progestogen-only contraception did not confer an increased risk of VTE in any study. The incidence rate of VTE in non-pregnant women aged 15-49 years using non-hormonal contraception is three per 10 000 years. For women starting on hormonal contraception, we recommend medium- or low-dose combined pills with norethisterone, LNG or norgestimate as first-choice preparations. For the many women who are users of COCs with newer progestogens, although the absolute risk of VTE is low, a change to combined pills with norethisterone, LNG or norgestimate may halve their risk of VTE. Finally, we recommend COCs with 20 μg estrogen combined with the older progestogens to be launched in the Scandinavian countries. Women at an increased risk of VTE should consider progestogen-only contraception or non-hormonal contraception.

Effectiveness of Long-Acting Reversible Contraception

BackgroundThe rate of unintended pregnancy in the United States is much higher than in other developed nations. Approximately half of unintended pregnancies are due to contraceptive failure, largely owing to inconsistent or incorrect use.MethodsWe designed a large prospective cohort study to promote the use of long-acting reversible contraceptive methods as a means of reducing unintended pregnancies in our region. Participants were provided with reversible contraception of their choice at no cost. We compared the rate of failure of long-acting reversible contraception (intrauterine devices [IUDs] and implants) with other commonly prescribed contraceptive methods (oral contraceptive pills, transdermal patch, contraceptive vaginal ring, and depot medroxyprogesterone acetate [DMPA] injection) in the overall cohort and in groups stratified according to age (less than 21 years of age vs. 21 years or older).ResultsAmong the 7486 participants included in this analysis, we identified 334 unintended pregnancies. The contraceptive failure rate among participants using pills, patch, or ring was 4.55 per 100 participant-years, as compared with 0.27 among participants using long-acting reversible contraception (hazard ratio after adjustment for age, educational level, and history with respect to unintended pregnancy, 21.8; 95% confidence interval, 13.7 to 34.9). Among participants who used pills, patch, or ring, those who were less than 21 years of age had a risk of unintended pregnancy that was almost twice as high as the risk among older participants. Rates of unintended pregnancy were similarly low among participants using DMPA injection and those using an IUD or implant, regardless of age.ConclusionsThe effectiveness of long-acting reversible contraception is superior to that of contraceptive pills, patch, or ring and is not altered in adolescents and young women. (Funded by the Susan Thompson Buffet Foundation.)

Clot Risk with Non-Oral Hormonal Contraception

Given that many people find remembering to take daily medications difficult, the convenience of the contraceptive patch (changed weekly) and ring