Practice changer
Recommend continuous or extended use of the transvaginal contraceptive ring to women who want fewer days of menstrual bleeding and have trouble remembering to, or prefer not to, take a daily pill. If breakthrough bleeding is troublesome, suggest a 4-day ring-free interval.1
Strength of recommendation
B: Based on a single randomized controlled trial (RCT) with <80% follow up.
Sulak PJ, Smith V, Coffee A, et al. Frequency and management of breakthrough bleeding with continuous use of the transvaginal contraceptive ring: a randomized controlled trial. Obstet Gynecol. 2008;112:563-571.
ILLUSTRATIVE CASE
Case 1: A healthy 25-year-old woman comes to see you because she’s worried about getting pregnant. She’s been on an extended-cycle oral contraceptive (OC) for several months and is happy to have her period only once every 3 months, but she frequently forgets to take her pill.
What can you offer that will give her the benefits of an extended-cycle OC, without the risk of pregnancy she incurs each time she misses a pill?
Case 2: You started a healthy 18-year-old on the transvaginal ring 6 months ago. After counseling, she opted for continuous cycling, so she inserts a new ring right after she removes the old one, on the same date each month. Although she likes the ring, she’s disturbed by a recent increase in breakthrough bleeding. What can you recommend to decrease the bleeding?
Clinicians have long known that the traditional 21/7 OC cycle is not necessary for safety or efficacy. More recently, many women have been happy to learn that there is no physiologic reason to have a monthly period when they’re using combination hormonal contraception. They’re also happy to discover that fewer periods often mean fewer premenstrual mood swings, episodes of painful cramping, and instances of other troublesome symptoms.
The transvaginal ring is often overlooked
The US Food and Drug Administration (FDA) has approved 2 combination OCs for extended-cycle use and 1 for continuous use. But any monophasic OC can be used off-label for extended or continuous cycling to decrease bleeding frequency. So, too, can the transvaginal contraceptive ring (NuvaRing), an infrequently used contraceptive. (According to 1 study, just 5.7% of US women using contraception used either the ring or the patch.2 ) The ring has been studied for extended use,3 but does not have FDA approval for longer-term regimens.
NuvaRing is a flexible, transparent device that contains the progestin etonogestrel and ethinyl estradiol. The manufacturer recommends a 21/7 cycle, inserting the ring in the vagina and leaving it in place for 3 weeks, removing it for 1 week, and then inserting a new ring.4 The ring is well suited to women who have no contraindications to hormonal contraception but have difficulty remembering to take a pill every day—or simply prefer the convenience of less frequent dosing.
While the ring has been found to be effective and tolerable when used without a hormone-free interval—28-, 49-, 91- and 364-day dosing has been studied—breakthrough bleeding or spotting is a frequent side effect of extended-cycle hormonal contraception. In 1 study, 43% of women on a 49-day ring cycle experienced breakthrough bleeding, compared with 16% of those on a 28-day cycle.3
High satisfaction, low risk
Nonetheless, women who use the transvaginal ring often report high satisfaction. One study found that 61% of women were very satisfied with this method of contraception, compared with 34% of triphasic OC users (P<.003).5 The risk of pregnancy (1-2 pregnancies per 100 women-years of use, according to the manufacturer4 ) and the risk of venous thromboembolism (10-30 in 100,000 vs 4-11 in 100,000 nonpregnant women who are not using hormonal contraception) are comparable to that of women using OCs.6,7 The risk of other severe side effects associated with the vaginal ring is comparable to that of OCs, as well.
STUDY SUMMARY: An effective option that women used post-trial
This RCT recruited women between the ages of 18 and 45 years who had been using combination hormonal contraceptives—OCs, the transdermal patch, or the transvaginal ring. All had been on a 21/7 cycle for at least 2 months. Exclusion criteria included a body mass index ≥38 kg/m2, smoking >10 cigarettes per day, use of other estrogen- or phytoestrogen-containing products, and the presence of ovarian cysts >2.5 cm or endometrial thickness >8 mm. Women who wanted to get pregnant within a year were also excluded.