Skip to main content
SpringerLink
Log in
Book cover

The Handbook of Contraception pp 73–96Cite as

The Contraceptive Vaginal Ring

  • Chapter
  • First Online:

  • 791 Accesses

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

Abstract

Contraceptive vaginal rings (CVR) are plastic polymer rings containing sex steroids that are directly absorbed through the vaginal epithelium into systemic circulation for highly effective contraception without the need for daily dosing. There are currently two CVRs that are FDA-approved for use in the United States. The ENG/EE ring (NuvaRing) contains etonogestrel (ENG) and ethinyl estradiol (EE) and was approved for use in the United States in 2001. It is the most widely used and studied CVR. The SA/EE ring (Annovera), which contains segesterone acetate (SA) and ethinyl estradiol (EE), was just approved by the FDA in 2018 and should be available within the next year. Both the ENG/EE and SA/EE rings are highly effective, similar to other combined hormonal methods, and have excellent cycle control. A third progesterone-only CVR, the Progering, is only available in Latin America for postpartum lactating women. This chapter primarily focuses on the ENG/EE ring but also includes currently available data on the SA/EE ring. Pharmacokinetics, mechanism of action, effectiveness, advantages and disadvantages, clinical use, and adverse effects of CVRs are addressed in this chapter.

This is a preview of subscription content, log in via an institution.

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  1. Contraceptive Use in the United States. 2004. Available from: https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states.

  2. Smith L. The Kahun gynaecological papyrus: ancient Egyptian medicine. J Fam Plann Reprod Health Care. 2011;37(1):54–5.

    PubMed  Google Scholar 

  3. Macht DI. On the absorption of drugs and poisons through the vagina. J Pharmacol Exp Ther. 1918;10(7):509–22.

    CAS  Google Scholar 

  4. Folkman J, Long DM. The use of silicone rubber as a carrier for prolonged drug therapy. J Surg Res. 2019;4(3):139–42.

    Google Scholar 

  5. Dziuk PJ, Cook B. Passage of steroids through silicone rubber. Endocrinology. 1966;78(1):208–11.

    CAS  PubMed  Google Scholar 

  6. Mishell DR Jr, et al. Contraception by means of a silastic vaginal ring impregnated with medroxyprogesterone acetate. Am J Obstet Gynecol. 1970;107(1):100–7.

    PubMed  Google Scholar 

  7. Koetsawang S, et al. Microdose intravaginal levonorgestrel contraception: a multicentre clinical trial. I. Contraceptive efficacy and side effects. World Health Organization. Task Force on Long-Acting Systemic Agents for Fertility Regulation. Contraception. 1990;41(2):105–24.

    CAS  PubMed  Google Scholar 

  8. Mishell DR Jr, et al. Clinical performance and endocrine profiles with contraceptive vaginal rings containing a combination of estradiol and d-norgestrel. Am J Obstet Gynecol. 1978;130(1):55–62.

    CAS  PubMed  Google Scholar 

  9. Mishell DR, Lumkin M, Jackanicz T. Initial clinical studies of intravaginal rings containing norethindrone and norgestrel. Contraception. 1975;12(3):253–60.

    PubMed  Google Scholar 

  10. Mishell DR Jr, Lumkin ME. Contraceptive effect of varying dosages of progestogen in silastic vaginal rings. Fertil Steril. 1970;21(2):99–103.

    PubMed  Google Scholar 

  11. Brache V, Faundes A. Contraceptive vaginal rings: a review. Contraception. 2010;82(5):418–27.

    CAS  PubMed  Google Scholar 

  12. Sivin I, et al. A multicenter study of levonorgestrel-estradiol contraceptive vaginal rings. I-use effectiveness. An international comparative trial. Contraception. 1981;24(4):341–58.

    CAS  PubMed  Google Scholar 

  13. Roy S, et al. The effect on lipids and lipoproteins of a contraceptive vaginal ring containing levonorgestrel and estradiol. Contraception. 1981;24(4):429–49.

    CAS  PubMed  Google Scholar 

  14. Adams MR, et al. Contraceptive steroids and coronary artery atherosclerosis in cynomolgus macaques. Fertil Steril. 1987;47(6):1010–8.

    CAS  PubMed  Google Scholar 

  15. Ballagh SA, et al. A contraceptive vaginal ring releasing norethindrone acetate and ethinyl estradiol. Contraception. 1994;50(6):517–33.

    CAS  PubMed  Google Scholar 

  16. Roumen FJ, et al. Efficacy, tolerability and acceptability of a novel contraceptive vaginal ring releasing etonogestrel and ethinyl oestradiol. Hum Reprod. 2001;16(3):469–75.

    CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  18. Roumen FJ. Review of the combined contraceptive vaginal ring, NuvaRing®. Ther Clin Risk Manag. 2008;4(2):441–51.

    PubMed  PubMed Central  Google Scholar 

  19. Ahrendt HJ, et al. Efficacy, acceptability and tolerability of the combined contraceptive ring, NuvaRing, compared with an oral contraceptive containing 30 microg of ethinyl estradiol and 3 mg of drospirenone. Contraception. 2006;74(6):451–7.

    CAS  PubMed  Google Scholar 

  20. Oddsson K, 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.

    CAS  PubMed  Google Scholar 

  21. Laurikka-Routti M, Haukkamaa M, Heikinheimo O. A contraceptive vaginal ring releasing ethinyl estradiol and the progestin ST-1435: bleeding control, serum steroid concentrations, serum lipids and serum chemistry. Contraception. 1990;42(1):111–20.

    CAS  PubMed  Google Scholar 

  22. Sivin I, et al. Contraceptive vaginal rings releasing Nestorone and ethinylestradiol: a 1-year dose-finding trial. Contraception. 2005;71(2):122–9.

    CAS  PubMed  Google Scholar 

  23. Jensen JT, et al. Continuous dosing of a novel contraceptive vaginal ring releasing Nestorone(R) and estradiol: pharmacokinetics from a dose-finding study. Contraception. 2018;97(5):422–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  24. Sitruk-Ware RM, et al. Efficacy, safety and acceptability of a new contraceptive vaginal ring delivering nestorone (150 ug) and ethinyl estradiol (15 ug) daily: results from a multi-center open label phase 3 clinical trial. Fertil Steril. 2013;100(3):S58.

    Google Scholar 

  25. FDA approves the first one-year contraceptive fully under a woman’s control. Population Council. 2018. Available from: https://www.popcouncil.org/news/fda-approves-the-first-one-year-contraceptive-fully-under-a-womans-control.

  26. Brache V, Payan LJ, Faundes A. Current status of contraceptive vaginal rings. Contraception. 2013;87(3):264–72.

    CAS  PubMed  Google Scholar 

  27. Archer DF, et al. Efficacy of the 1-year (13-cycle) segesterone acetate and ethinylestradiol contraceptive vaginal system: results of two multicentre, open-label, single-arm, phase 3 trials. Lancet Glob Health. 2019;7:e1054–64.

    PubMed  PubMed Central  Google Scholar 

  28. Kerns J, Darney P. Vaginal ring contraception. Contraception. 2011;83(2):107–15.

    CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  30. Dragoman M, et al. Contraceptive vaginal ring effectiveness is maintained during six weeks use: a prospective study of normal BMI and obese women. Contraception. 2013;87(4):432–6.

    CAS  PubMed  Google Scholar 

  31. van den Heuvel MW, et al. 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.

    PubMed  Google Scholar 

  32. Roumen FJ, Dieben TO. Comparison of uterine concentrations of ethinyl estradiol and etonogestrel after use of a contraceptive vaginal ring and an oral contraceptive. Fertil Steril. 2006;85(1):57–62.

    CAS  PubMed  Google Scholar 

  33. Drug Approval Package: NuvaRing (etonogestrel/ethinyl estradiol) vaginal ring. 2015. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/nda/2013/021187Orig1s021s022TOC.cfm.

  34. Drug Approval Package: Annovera (segesterone acetate and ethinyl estradiol). 2018. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/nda/2018/209627Orig1s000TOC.cfm.

  35. Baird DT, Glasier AF. Hormonal contraception. N Engl J Med. 1993;328(21):1543–9.

    CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  37. Schreiber CA, Barnhart K. Chapter 36 – Contraception. In: Strauss JF, Barbieri RL, editors. Yen & Jaffe’s reproductive endocrinology. 7th ed. Philadelphia: W.B. Saunders; 2014. p. 890–908.e3.

    Google Scholar 

  38. Roumen FJ, Mishell DR Jr. The contraceptive vaginal ring, NuvaRing((R)), a decade after its introduction. Eur J Contracept Reprod Health Care. 2012;17(6):415–27.

    PubMed  Google Scholar 

  39. Roumen FJ, op ten Berg MM, Hoomans EH. The combined contraceptive vaginal ring (NuvaRing): first experience in daily clinical practice in the Netherlands. Eur J Contracept Reprod Health Care. 2006;11(1):14–22.

    CAS  PubMed  Google Scholar 

  40. Mulders TM, Dieben TO, Bennink HJ. Ovarian function with a novel combined contraceptive vaginal ring. Hum Reprod. 2002;17(10):2594–9.

    PubMed  Google Scholar 

  41. Westhoff CL, et al. Pharmacokinetics and ovarian suppression during use of a contraceptive vaginal ring in normal-weight and obese women. Am J Obstet Gynecol. 2012;207(1):39.e1–6.

    PubMed  Google Scholar 

  42. Verhoeven CH, Dieben TO. The combined contraceptive vaginal ring, NuvaRing, and tampon co-usage. Contraception. 2004;69(3):197–9.

    CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  44. Dogterom P, van den Heuvel MW, Thomsen T. Absence of pharmacokinetic interactions of the combined contraceptive vaginal ring NuvaRing with oral amoxicillin or doxycycline in two randomised trials. Clin Pharmacokinet. 2005;44(4):429–38.

    CAS  PubMed  Google Scholar 

  45. Verhoeven CH, et al. The contraceptive vaginal ring, NuvaRing, and antimycotic co-medication. Contraception. 2004;69(2):129–32.

    CAS  PubMed  Google Scholar 

  46. Simmons KB, et al. Effects of concurrent vaginal miconazole treatment on the absorption and exposure of Nestorone(R) (segesterone acetate) and ethinyl estradiol delivered from a contraceptive vaginal ring: a randomized, crossover drug-drug interaction study. Contraception. 2018;97(3):270–6.

    CAS  PubMed  Google Scholar 

  47. Creinin MD, et al. Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial. Obstet Gynecol. 2008;111(2 Pt 1):267–77.

    PubMed  Google Scholar 

  48. Novak A, et al. The combined contraceptive vaginal ring, NuvaRing: an international study of user acceptability. Contraception. 2003;67(3):187–94.

    CAS  PubMed  Google Scholar 

  49. Birgisson NE, et al. Preventing unintended pregnancy: the contraceptive CHOICE project in review. J Womens Health (Larchmt). 2015;24:349–53.

    Google Scholar 

  50. Lete I, et al. Continuation rate of combined hormonal contraception: a prospective multicenter study. J Womens Health (Larchmt). 2012;21(5):490–5.

    Google Scholar 

  51. Sabatini R, Cagiano R. Comparison profiles of cycle control, side effects and sexual satisfaction of three hormonal contraceptives. Contraception. 2006;74(3):220–3.

    PubMed  Google Scholar 

  52. Stewart FH, et al. Adolescent and young women's experience with the vaginal ring and oral contraceptive pills. J Pediatr Adolesc Gynecol. 2007;20(6):345–51.

    PubMed  PubMed Central  Google Scholar 

  53. Lete I, et al. Self-described impact of noncompliance among users of a combined hormonal contraceptive method. Contraception. 2008;77(4):276–82.

    PubMed  Google Scholar 

  54. Oddsson K, et al. Superior cycle control with a contraceptive vaginal ring compared with an oral contraceptive containing 30 microg ethinylestradiol and 150 microg levonorgestrel: a randomized trial. Hum Reprod. 2005;20(2):557–62.

    CAS  PubMed  Google Scholar 

  55. Miller L, Verhoeven CH, Hout J. Extended regimens of the contraceptive vaginal ring: a randomized trial. Obstet Gynecol. 2005;106(3):473–82.

    PubMed  Google Scholar 

  56. Guazzelli CA, et al. Extended regimens of the vaginal contraceptive ring: cycle control. Contraception. 2009;80(5):430–5.

    PubMed  Google Scholar 

  57. Vercellini P, et al. Comparison of contraceptive ring and patch for the treatment of symptomatic endometriosis. Fertil Steril. 2010;93(7):2150–61.

    CAS  PubMed  Google Scholar 

  58. Cagnacci A, et al. Route of administration of contraceptives containing desogestrel/etonorgestrel and insulin sensitivity: a prospective randomized study. Contraception. 2009;80(1):34–9.

    CAS  PubMed  Google Scholar 

  59. US Medical Eligibility Criteria – Reproductive Health. CDC. 2016. Available from: https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html.

  60. Schwan A, Ahren T, Victor A. Effects of contraceptive vaginal ring treatment on vaginal bacteriology and cytology. Contraception. 1983;28(4):341–7.

    CAS  PubMed  Google Scholar 

  61. Roy S, Wilkins J, Mishell DR Jr. The effect of a contraceptive vaginal ring and oral contraceptives on the vaginal flora. Contraception. 1981;24(4):481–91.

    CAS  PubMed  Google Scholar 

  62. Lidegaard O, et al. Hormonal contraception and risk of venous thromboembolism: national follow-up study. BMJ. 2009;339:b2890.

    PubMed  PubMed Central  Google Scholar 

  63. Kemmeren JM, Algra A, Grobbee DE. Third generation oral contraceptives and risk of venous thrombosis: meta-analysis. BMJ. 2001;323(7305):131–4.

    CAS  PubMed  PubMed Central  Google Scholar 

  64. Ouellet-Hellstrom R, Graham DJ, Staffa JA. Combined hormonal contraceptives (CHCs) and the risk of cardiovascular disease endpoints report. FDA. 2011. Available from: https://www.fda.gov/media/82335.

  65. 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.

    PubMed  Google Scholar 

  66. Tuppurainen M, et al. The combined contraceptive vaginal ring (NuvaRing) and lipid metabolism: a comparative study. Contraception. 2004;69(5):389–94.

    CAS  PubMed  Google Scholar 

  67. Barreiros FA, et al. Extended regimens of the combined contraceptive vaginal ring containing etonogestrel and ethinyl estradiol: effects on lipid metabolism. Contraception. 2011;84(2):155–9.

    CAS  PubMed  Google Scholar 

  68. Schafer JE, et al. Acceptability and satisfaction using Quick Start with the contraceptive vaginal ring versus an oral contraceptive. Contraception. 2006;73(5):488–92.

    PubMed  Google Scholar 

  69. Guida M, et al. Effects of two types of hormonal contraception--oral versus intravaginal--on the sexual life of women and their partners. Hum Reprod. 2005;20(4):1100–6.

    CAS  PubMed  Google Scholar 

  70. RamaRao S, et al. Progesterone vaginal ring: introducing a contraceptive to meet the needs of breastfeeding women. Contraception. 2013;88(5):591–8.

    CAS  PubMed  Google Scholar 

  71. Croxatto SD, et al. Fertility regulation in nursing women: VIII. Progesterone plasma levels and contraceptive efficacy of a progesterone-releasing vaginal ring. Contraception. 1985;32(6):603–22.

    Google Scholar 

  72. Nath A, Sitruk-Ware R. Progesterone vaginal ring for contraceptive use during lactation. Contraception. 2010;82(5):428–34.

    CAS  PubMed  Google Scholar 

  73. Diaz S, et al. Fertility regulation in nursing women: VIII. Progesterone plasma levels and contraceptive efficacy of a progesterone-releasing vaginal ring. Contraception. 1985;32(6):603–22.

    CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  75. Nel A, et al. Safety and efficacy of a dapivirine vaginal ring for HIV prevention in women. N Engl J Med. 2016;375(22):2133–43.

    CAS  PubMed  Google Scholar 

  76. Baeten JM, et al. Use of a vaginal ring containing dapivirine for HIV-1 prevention in women. N Engl J Med. 2016;375(22):2121–32.

    CAS  PubMed  PubMed Central  Google Scholar 

  77. Dapivirine Ring. International Partnership for Microbicides (IPM). 2019. Available from: https://www.ipmglobal.org/our-work/our-products/dapivirine-ring.

  78. Thurman AR, et al. Randomized, placebo controlled phase I trial of safety, pharmacokinetics, pharmacodynamics and acceptability of tenofovir and tenofovir plus levonorgestrel vaginal rings in women. PLoS One. 2018;13(6):e0199778.

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA

    Rachel S. Mandelbaum

  2. Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Keck Medical School at the University of Southern California, Los Angeles, CA, USA

    Donna Shoupe

  3. Department of Family Medicine, Keck School of Medicine at USC, Los Angeles, CA, USA

    Donna Shoupe

Authors
  1. Rachel S. Mandelbaum
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Donna Shoupe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rachel S. Mandelbaum .

Editor information

Editors and Affiliations

  1. Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Donna Shoupe

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Mandelbaum, R.S., Shoupe, D. (2020). The Contraceptive Vaginal Ring. In: Shoupe, D. (eds) The Handbook of Contraception. Current Clinical Practice. Humana, Cham. https://doi.org/10.1007/978-3-030-46391-5_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-46391-5_5

  • Published:

  • Publisher Name: Humana, Cham

  • Print ISBN: 978-3-030-46390-8

  • Online ISBN: 978-3-030-46391-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation