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Part of the book series: Current Clinical Practice ((CCP))

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Abstract

Contraceptive vaginal rings (CVR) offer the benefit of safe, effective, and patient-controlled reversible contraception without the need for daily dosing. There are currently two CVRs in commercial use worldwide, including the etonogestrel/ethinyl estradiol (ENG/EE) CVR and a progesterone-only ring approved in some countries for postpartum lactating women. This chapter focuses on the ENG/EE CVR (NuvaRing®) approved by the US FDA. Pharmacokinetics, mechanism of action, effectiveness, advantages and disadvantages, and counseling tips are addressed. Additionally, this chapter includes a discussion of drug interactions and side effects, including the risk of venous and arterial thromboembolism with vaginal as compared to oral ethinyl estradiol.

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References

  1. Bahamondes L, Bahamondes MV. New and emerging contraceptives: a state-of-the-art review. Int J Womens Health. 2014;4(6):221–34.

    Article  Google Scholar 

  2. Jensen JT. Vaginal ring delivery of selective progesterone receptor modulators for contraception. Contraception. 2013;87(3):314–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  3. Brache V, Sitruk-Ware R, Williams A, Blithe D, Croxatto H, Kumar N, et al. Effects of a novel estrogen-free, progesterone receptor modulator contraceptive vaginal ring on inhibition of ovulation, bleeding patterns and endometrium in normal women. Contraception. 2012;85(5):480–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  4. Mohamed AMM, El-Sherbiny WSM, Mostafa WAI. Combined contraceptive ring versus combined oral contraceptive (30 mcg ethinylestradiol and 3-mg drospirenone). Int J Gynecol Obstet. 2011;114(2):145–8.

    Article  CAS  Google Scholar 

  5. Goldzieher JW, Stanczyk FZ. Oral contraceptives and individual variability of circulating levels of ethinyl estradiol and progestins. Contraception. 2008;78(1):4–9.

    Article  CAS  PubMed  Google Scholar 

  6. Timmer C, Mulders TM. Pharmacokinetics of etonogestrel and ethinylestradiol released from a combined contraceptive vaginal ring. Clin Pharmacokinet. 2000;39(3):233–42.

    Article  CAS  PubMed  Google Scholar 

  7. van den Heuvel MW, van Bragt AJM, Alnabawy AKM, Kaptein MCJ. Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: the vaginal ring, the transdermal patch and an oral contraceptive. Contraception. 2005;72(3):168–74.

    Article  PubMed  Google Scholar 

  8. Bruni V, Pontello V, Luisi S, Petraglia F. An open-label, multicentre trial to evaluate the vaginal bleeding pattern of the combined contraceptive vaginal ring NuvaRing®. Eur J Obstet Gynecol Reprod Biol. 2008;139(1):65–71.

    Article  CAS  PubMed  Google Scholar 

  9. Mulders TM, Dieben TOM. Use of the novel combined contraceptive vaginal ring NuvaRing for ovulation inhibition. Fertil Steril. 2001;75(5):865–70.

    Article  CAS  PubMed  Google Scholar 

  10. Dragoman M, Petrie K, Torgal A, Thomas T, Cremers S, Westhoff CL. Contraceptive vaginal ring effectiveness is maintained during 6 weeks of use: a prospective study of normal BMI and obese women. Contraception. 2013;87(4):432–6.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  11. Fritz MA, Speroff L. Clinical gynecologic endocrinology and infertility. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

    Google Scholar 

  12. Mulders TMT, Dieben TOM, Coelingh Bennick H. Ovarian function with a novel combined contraceptive vaginal ring. Hum Reprod. 2002;17(10):2594–9.

    Article  PubMed  Google Scholar 

  13. Hatcher R, Trussell J, Nelson AL, Cates W. Contraceptive technology. 20th ed. Tiger, GA: Bridging the Gap Foundation; 2011.

    Google Scholar 

  14. Durand M, Seppala M, Cravioto MDC, Koistinen H, Koistinen R, González-Macedo J, et al. Late follicular phase administration of levonorgestrel as an emergency contraceptive changes the secretory pattern of glycodelin in serum and endometrium during the luteal phase of the menstrual cycle. Contraception. 2005;71(6):451–7.

    Article  CAS  PubMed  Google Scholar 

  15. Winner B, Peipert JF, Zhao Q, Buckel C, Madden TE, Allsworth JE, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998–2007.

    Article  CAS  PubMed  Google Scholar 

  16. Dieben T, Roumen F, Apter D. Efficacy, cycle control, and user acceptability of a novel combined contraceptive vaginal ring. Obstet Gynecol. 2002;100(3):585–93.

    Article  CAS  PubMed  Google Scholar 

  17. Oddsson K, Leifels-Fischer B, de Melo NR, Wiel-Masson D, Benedetto C, Verhoeven CHJ, et al. Efficacy and safety of a contraceptive vaginal ring (NuvaRing) compared with a combined oral contraceptive: a 1-year randomized trial. Contraception. 2005;71(3):176–82.

    Article  CAS  PubMed  Google Scholar 

  18. Westhoff C. Higher body weight does not affect NuvaRing’s efficacy (abstract). Obstet Gynecol. 2005;105(4S):56S.

    Google Scholar 

  19. McNicholas C, Zhao Q, Secura G, Allsworth JE, Madden T, Peipert JF. Contraceptive failures in overweight and obese combined hormonal contraceptive users. Obstet Gynecol. 2013;121(3):585–92.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Peipert JF, Zhao Q, Allsworth JE, Petrosky E, Madden T, Eisenberg D, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105–13.

    Article  PubMed Central  PubMed  Google Scholar 

  21. Gilliam ML, Neustadt A, Kozloski M, Mistretta S, Tilmon S, Godfrey EM. Adherence and acceptability of the contraceptive ring compared with the pill among students. Obstet Gynecol. 2010;115(3):503–10.

    Article  PubMed  Google Scholar 

  22. Stewart FH, Brown BA, Raine TR, Weitz TA, Harper CC. Adolescent and young women’s experience with the vaginal ring and oral contraceptive pills. J Pediatr Adolesc Gynecol. 2007;20(6):345–51.

    Article  PubMed Central  PubMed  Google Scholar 

  23. Ballagh S, Babb T, Kovalevsky G, Archer DF. Contraceptive ring compliance: as labeled versus calendar based use. Fertil Steril. 2003;80(3):S54.

    Article  Google Scholar 

  24. Creinin MD, Meyn L, Borgatta L, Barnhart KT, Jensen JT, Burke AE, et al. Multicenter comparison of the contraceptive ring and patch. Obstet Gynecol. 2008;111(2):267–77.

    Article  PubMed  Google Scholar 

  25. Bjarnadóttir RI, Tuppurainen M, Killick SR. Comparison of cycle control with a combined contraceptive vaginal ring and oral levonorgestrel/ethinyl estradiol. Am J Obstet Gynecol. 2002;186(3):389–95.

    Article  PubMed  Google Scholar 

  26. Oddsson K. Superior cycle control with a contraceptive vaginal ring compared with an oral contraceptive containing 30 g ethinylestradiol and 150 g levonorgestrel: a randomized trial. Hum Reprod. 2004;20(2):557–62.

    Article  PubMed  Google Scholar 

  27. Miller L, Verhoeven CHJ, Hout J. Extended regimens of the contraceptive vaginal ring. Obstet Gynecol. 2005;106(3):473–82.

    Article  PubMed  Google Scholar 

  28. Guazzelli CAF, Barreiros FA, Barbosa R, de Araújo FF, Moron AF. Extended regimens of the vaginal contraceptive ring: cycle control. Contraception. 2009;80(5):430–5.

    Article  PubMed  Google Scholar 

  29. Veres S, Miller L, Burington B. A comparison between the vaginal ring and oral contraceptives. Obstet Gynecol. 2004;104(3):555–63.

    Article  PubMed  Google Scholar 

  30. Rad M, Kluft C, Menard J, Burggraaf J, de Kam ML, Meijer P, et al. Comparative effects of a contraceptive vaginal ring delivering a nonandrogenic progestin and continuous ethinyl estradiol and a combined oral contraceptive containing levonorgestrel on hemostasis variables. Am J Obstet Gynecol. 2006;195(1):72–7.

    Article  CAS  PubMed  Google Scholar 

  31. Jensen JT, Burke AE, Barnhart KT, Tillotson C, Messerle-Forbes M, Peters D. Effects of switching from oral to transdermal or transvaginal contraception on markers of thrombosis. Contraception. 2008;78:1–8.

    Article  Google Scholar 

  32. Magnusdóttir EM, Bjarnadóttir RI, Önundarson PT, Gudmundsdóttir BR, Geirsson RT, Magnusdóttir SD, et al. The contraceptive vaginal ring (NuvaRing®) and hemostasis: a comparative study. Contraception. 2004;69(6):461–7.

    Article  PubMed  Google Scholar 

  33. Grimes DA, Schulz KF, Raymond E. Surrogate end points in women’s health research: science, protoscience, and pseudoscience. Fertil Steril. 2010;93(6):1731–4.

    Article  PubMed  Google Scholar 

  34. Ouellet-Hellstrom R, Graham DJ. Combined hormonal contraceptives (CHCs) and the risk of cardiovascular disease endpoints. FDA Office of Surveillance and Epidemiology. 2011;1–57.

    Google Scholar 

  35. Sidney S, Cheetham TC, Connell FA, Ouellet-Hellstrom R, Graham DJ, Davis D, et al. Recent combined hormonal contraceptives (CHCs) and the risk of thromboembolism and other cardiovascular events in new users. Contraception. 2013;87(1):93–100.

    Article  CAS  PubMed  Google Scholar 

  36. 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.

    Article  PubMed Central  PubMed  Google Scholar 

  37. Dinger J, Möhner S, Heinemann K. Cardiovascular risk associated with the use of an etonogestrel-containing vaginal ring. Obstet Gynecol. 2013;122(4):800–8.

    Article  PubMed  Google Scholar 

  38. Abdul Sultan A, Tata LJ, Grainge MJ, West J. The incidence of first venous thromboembolism in and around pregnancy using linked primary and secondary care data: a population based cohort study from England and comparative meta-analysis. PLoS One. 2013;8(7):e70310.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  39. Meng K, Hu X, Peng X, Zhang Z. Incidence of venous thromboembolism during pregnancy and the puerperium: a systematic review and meta-analysis. J Matern Fetal Neonatal Med. 2015;28:1–9.

    Article  Google Scholar 

  40. Virkus R, Lokkegaard E, Lindegaard O, Langhoff-Roos J, Nielson A, Rothman K, et al. Risk factors for venous thromboembolism in 1.3 million pregnancies: a nationwide prospective cohort. PLoS One. 2014;9(5):e96495.

    Article  PubMed Central  PubMed  Google Scholar 

  41. Pomp E, Lenselink A, Rosendaal FR, Doggen CJM. Pregnancy, the postpartum period and prothrombotic defects: risk of venous thrombosis in the MEGA study. J Thromb Haemost. 2008;6(4):632–7.

    Article  CAS  PubMed  Google Scholar 

  42. Nightingale AL, Lawrenson RA, Simpson EL, Williams TJ, MacRae KD, Farmer RD. The effects of age, body mass index, smoking and general health on the risk of venous thromboembolism in users of combined oral contraceptives. Eur J Contracept Reprod Health Care. 2000;5(4):265–74.

    Article  CAS  PubMed  Google Scholar 

  43. Canonico M, Oger E, Plu-Bureau G, Conard J, Meyer G, Levesque H, et al. Hormone therapy and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration and progestogens: the ESTHER study. Circulation. 2007;115(7):840–5.

    Article  CAS  PubMed  Google Scholar 

  44. Lidegaard O, Lokkegaard E, Jensen A, Skovlund C, Keiding N. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med. 2012;366(24):2257–66.

    Article  CAS  PubMed  Google Scholar 

  45. Gallo MF, Lopez LM, Schulz KF, Helmerhorst FM. Combination contraceptives: effects on weight (Review). Cochrane Database Syst Rev. 2012;1–116.

    Google Scholar 

  46. O’Connell KJ, Osborne LM, Westhoff C. Measured and reported weight change for women using a vaginal contraceptive ring vs. a low-dose oral contraceptive. Contraception. 2005;72(5):323–7.

    Article  PubMed  Google Scholar 

  47. Tuppurainen M, Klimscheffskij R, Venhola M, Dieben TOM. The combined contraceptive vaginal ring (NuvaRing®) and lipid metabolism: a comparative study. Contraception. 2004;69(5):389–94.

    Article  CAS  PubMed  Google Scholar 

  48. Elkind-Hirsch KE, Darensbourg C, Ogden B, Ogden LF, Hindelang P. Contraceptive vaginal ring use for women has less adverse metabolic effects than an oral contraceptive. Contraception. 2007;76(5):348–56.

    Article  CAS  PubMed  Google Scholar 

  49. Barnhart KT, Schreiber C. Return to fertility following discontinuation of oral contraceptives. Fertil Steril. 2009;91(3):659–63.

    Article  PubMed  Google Scholar 

  50. Raman-Wilms L, Tseng A, Wighardt S, Einarson T, Koren G. Fetal genital effects of first-trimester sex hormone exposure: a meta-analysis. Obstet Gynecol. 1995;85(1):1–9.

    Article  Google Scholar 

  51. Nelson HD, Zakher B, Cantor A, Fu R, Griffin J. Risk factors for breast cancer for women age 40–49: systematic review and meta analysis. Ann Intern Med. 2013;156(9):635–48.

    Article  Google Scholar 

  52. Marchbanks PA, McDonald JA, Wilson HG, Folger SG, Mandel MG, Daling J, et al. Oral contraceptives and the risk of breast cancer. N Engl J Med. 2002;346(26):2025–32.

    Article  CAS  PubMed  Google Scholar 

  53. Moorman PG, Havrilesky LJ, Gierisch JM, Coeytaux RR, Lowery WJ, Peragallo Urrutia R, et al. Oral contraceptives and risk of ovarian cancer and breast cancer among high-risk women: a systematic review and meta-analysis. J Clin Oncol. 2013;31(33):4188–98.

    Article  CAS  PubMed  Google Scholar 

  54. Milne RL, Knight JA, Esther JM. Oral contraceptive use and risk of early-onset breast cancer in carriers and noncarriers of BRCA1 and BRCA2 mutations. Cancer Epidemiol Biomarkers Prev. 2005;14(2):350–6.

    Article  CAS  PubMed  Google Scholar 

  55. Friebel TM, Domchek SM, Rebbeck TR. Modifiers of cancer risk in BRCA1 and BRCA2 mutation carriers: systematic review and meta-analysis. J Natl Cancer Inst. 2014;106(6):dju091–1.

    Article  PubMed Central  PubMed  Google Scholar 

  56. Cibula D, Gompel A, Mueck AO, La Vecchia C, Hannaford PC, Skouby SO, et al. Hormonal contraception and risk of cancer. Hum Reprod Update. 2010;16(6):631–50.

    Article  CAS  PubMed  Google Scholar 

  57. Center for Disease Control. U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Morb Mortal Wkly Rep. 2010;59:1–88.

    Google Scholar 

  58. Verhoeven CHJ, van den Heuvel MW, Mulders TMT, Dieben TOM. The contraceptive vaginal ring, NuvaRing®, and antimycotic co-medication. Contraception. 2004;69(2):129–32.

    Article  CAS  PubMed  Google Scholar 

  59. Verhoeven CHJ, Dieben TOM. The combined contraceptive vaginal ring, NuvaRing®, and tampon co-usage. Contraception. 2004;69(3):197–9.

    Article  CAS  PubMed  Google Scholar 

  60. Haring T, Mulders TMT. The combined contraceptive ring NuvaRing® and spermicide co-medication. Contraception. 2003;67(4):271–2.

    Article  CAS  PubMed  Google Scholar 

  61. Christensen J, Petrenaite V, Atterman J, Sidenius P, Öhman I, Tomson T, et al. Oral contraceptives induce lamotrigine metabolism: evidence from a double-blind, placebo-controlled trial. Epilepsia. 2007;48(3):484–9.

    Article  CAS  PubMed  Google Scholar 

  62. Tepper NK, Curtis KM, Steenland MW, Marchbanks PA. Physical examination prior to initiating hormonal contraception: a systematic review. Contraception. 2013;87(5):650–4.

    Article  PubMed  Google Scholar 

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Correspondence to Katharine B. Simmons MD, MPH .

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Simmons, K.B., Jensen, J.T. (2016). Contraceptive Ring. In: Shoupe, D., Mishell, Jr., D. (eds) The Handbook of Contraception. Current Clinical Practice. Humana Press, Cham. https://doi.org/10.1007/978-3-319-20185-6_7

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  • DOI: https://doi.org/10.1007/978-3-319-20185-6_7

  • Publisher Name: Humana Press, Cham

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