Pharmacodynamic correlations using fresh and cryopreserved tissue following use of vaginal rings containing dapivirine and/or maraviroc in a randomized, placebo controlled trial

BACKGROUND

The ex vivo challenge assay is a bio-indicator of drug efficacy and was utilized in this randomized, placebo controlled trial as one of the exploratory endpoints. Fresh and cryopreserved tissues were evaluated for human immunodeficiency virus (HIV) infection and pharmacokinetic (PK)/pharmacodynamic (PD) relationships.

METHODS

HIV-negative women used vaginal rings containing 25 mg dapivirine (DPV)/100 mg maraviroc (MVC) (n = 12), DPV only (n = 12), MVC only (n = 12), or placebo (n = 12) for 28 days. Blood plasma, cervicovaginal fluid (CVF), and cervical biopsies were collected for drug quantification and the ex vivo challenge assay; half (fresh) were exposed immediately to HIV while the other half were cryopreserved, thawed, then exposed to HIV. HIV replication was monitored by p24 enzyme-linked immunosorbent assay from culture supernatant. Data were log-transformed and analyzed by linear least squared regression, nonlinear Emax dose-response model and Satterthwaite t test.

RESULTS

HIV replication was greater in fresh compared to cryopreserved tissue (P = 0.04). DPV was detected in all compartments, while MVC was consistently detected only in CVF. Significant negative correlations between p24 and DPV levels were observed in fresh cervical tissue (P = 0.01) and CVF (P = 0.03), but not plasma. CVF MVC levels showed a significant negative correlation with p24 levels (P = 0.03); drug levels in plasma and tissue were not correlated with HIV suppression. p24 levels from cryopreserved tissue did not correlate to either drug from any compartment.

CONCLUSION

Fresh tissue replicated HIV to greater levels and defined PK/PD relationships while cryopreserved tissue did not. The ex vivo challenge assay using fresh tissue could prioritize drugs being considered for HIV prevention.

Pharmacologic Therapies in Women's Health: Contraception and Menopause Treatment

Female hormones play a significant role in the etiology and treatment of many women's health conditions. This article focuses on the common uses of hormonal therapy. When prescribing estrogen-containing regimens throughout the span of a woman's life, the risks are similar (ie, cardiovascular risk and venous thromboembolism), but the degree of risk varies significantly depending on a woman's particular set of risk factors and the details of the hormone regimen. In addition to estrogens and progestogens, this article also touches on the use of selective steroid receptor modulators in emergency contraception and in treatment of menopause symptoms.

Topical Delivery of Tenofovir Disoproxil Fumarate and Emtricitabine from Pod-Intravaginal Rings Protects Macaques from Multiple SHIV Exposures

Topical preexposure prophylaxis (PrEP) against HIV has been marginally successful in recent clinical trials with low adherence rates being a primary factor for failure. Controlled, sustained release of antiretroviral (ARV) drugs may help overcome these low adherence rates if the product is protective for extended periods of time. The oral combination of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) is currently the only FDA-approved ARV drug for HIV PrEP. A novel pod-intravaginal ring (IVR) delivering TDF and FTC at independently controlled rates was evaluated for efficacy at preventing SHIV162p3 infection in a rigorous, repeat low-dose vaginal exposure model using normally cycling female pigtailed macaques. Six macaques received pod-IVRs containing TDF (65 mg) and FTC (68 mg) every two weeks, and weekly vaginal exposures to 50 TCID₅₀ of SHIV162p3 began one week after the first pod-IVR insertion. All pod-IVR-treated macaques were fully protected throughout the study (P = 0.0002, Log-rank test), whereas all control animals became infected with a median of 4 exposures to infection. The topical, sustained release of TDF and FTC from the pod-IVR maintained protective drug levels in macaques over four months of virus exposures. This novel and versatile delivery system has the capacity to deliver and maintain protective levels of multiple drugs and the protection observed here warrants clinical evaluation of this pod-IVR design.

Eliminating health disparities in unintended pregnancy with long-acting reversible contraception (LARC)

Significant public health disparities exist surrounding teen and unplanned pregnancy in the United States. Women of color and those with lower education and socioeconomic status are at much greater risk of unplanned pregnancy and the resulting adverse outcomes. Unplanned pregnancies reduce educational and career opportunities and may contribute to socioeconomic deprivation and widening income disparities. Long-acting reversible contraception (LARC), including intrauterine devices and implants, offer the opportunity to change the default from drifting into parenthood to planned conception. LARC methods are forgettable; once placed, they offer highly effective, long-term pregnancy prevention. Increasing evidence in the medical literature demonstrates the population benefits of use of these methods. However, barriers to more widespread use of LARC methods persist and include educational, access, and cost barriers. With increasing insurance coverage under the Affordable Care Act and more widespread, no-cost coverage of methods, more and more women are choosing intrauterine devices and the contraceptive implant. Increasing the use of highly effective contraceptive methods may provide one solution to the persistent problem of the health disparities of unplanned and teen pregnancies in the United States and improve women's and children's health.

Monthly Periods--Are They Necessary?

Menstrual suppression--the use of hormones to delay or eliminate menses--is often used in adolescents to manage conditions associated with the menstrual cycle and to accommodate lifestyle preferences. Reducing the frequency of menstrual bleeding does not cause any known physiologic harm and has potential short-term and long-term advantages. Different methods used for menstrual suppression, however, have associated risks and side effects that need to be weighed against the benefits of controlling menses. This article reviews the advantages and disadvantages of menstrual suppression and the different methods available for adolescents.

Long-acting reversible contraception: who, what, when, and how

This review provides practical tips--and dispels some common misconceptions--about these devices, which have higher rates of patient satisfaction and lower rates of failure than any other reversible contraceptives..

The sheep as a model of preclinical safety and pharmacokinetic evaluations of candidate microbicides

When developing novel microbicide products for the prevention of HIV infection, the preclinical safety program must evaluate not only the active pharmaceutical ingredient but also the product itself. To that end, we applied several relatively standard toxicology study methodologies to female sheep, incorporating an assessment of the pharmacokinetics, safety, tolerability, and local toxicity of a dapivirine-containing human vaginal ring formulation (Dapivirine Vaginal Ring-004). We performed a 3-month general toxicology study, a preliminary pharmacokinetic study using drug-loaded vaginal gel, and a detailed assessment of the kinetics of dapivirine delivery to plasma, vaginal, and rectal fluid and rectal, vaginal, and cervical tissue over 28 days of exposure and 3 and 7 days after removal of the ring. The findings of the general toxicology study supported the existing data from both preclinical and clinical studies in that there were no signs of toxicity related to dapivirine. In addition, the presence of the physical dapivirine ring did not alter local or systemic toxicity or the pharmacokinetics of dapivirine. Pharmacokinetic studies indicated that the dapivirine ring produced significant vaginal tissue levels of dapivirine. However, no dapivirine was detected in cervical tissue samples using the methods described here. Plasma and vaginal fluid levels were lower than those in previous clinical studies, while there were detectable dapivirine levels in the rectal tissue and fluid. All tissue and fluid levels tailed off rapidly to undetectable levels following removal of the ring. The sheep represents a very useful model for the assessment of the safety and pharmacokinetics of microbicide drug delivery devices, such as the vaginal ring.

[Abortifacient effect of hormonal contraceptives: a review]

Most of the scientific community, as well as in a sector of international Law, when referring to the unborn embryo, pregnancy must be defined as the period extending from implantation to natural birth. This implies some novelty, such as the redefinition of abortion as the elimination of the embryo only within this period, and the extension of contraception to any means that impedes the union of the gametes as a consequence of a sexual intercourse, or also that which eliminates the product of conception prior to its implantation. Therefore, the pharmaceutical industry markets, under the name of contraceptives, products that act also by means of an anti-implantation mechanism. This fact has great ethical implications regarding the respect for the embryo which require a reflection on the moral valuation of the prescription, dispensation and use of these means. One may ask: which of the contraceptive means actually present in the market include an anti-implantation effect? What mechanisms contribute to their pharmacological action and in what measure do they do this? This is what we have studied in this article, based on the available scientific bibliography. We have basically fulfilled a double objective: updating and completing the studies -few, partial or distant in time- that had this same subject matter; and offering a moral valuation on the use of hormonal contraceptives that may have an anti-implantation effect, from the point of view of the respect due to the embryonic life.

'Men don't need to know everything': a field trial of a discreet, female-initiated, contraceptive barrier method (FemCap™) among Haitian-American women

Worldwide, women report the need for safe, non-hormonal, woman-initiated methods of family planning. Cervical barriers provide such technology but are under-researched and under-promoted. In the USA, there are few studies of cervical barriers among women at high unmet need for contraception. A feasibility study of the FemCap™ was conducted among US women of Haitian origin. Participants were heterosexual and seeking to avoid pregnancy. At first visit, participants completed baseline assessments, underwent group counselling and were fitted with FemCap™. Women were asked to insert or use the cap at home. The second visit (2-3 weeks) included an interviewer-administered questionnaire and a focus-group discussion. Participants (n  =  20) were Haitian-born (70%), married (55%) and parous (85%). Their mean age was 32.6 years. Seventy percent reported recent unprotected sex. All women inserted the device at home and 9 women used it during intercourse, including 5 without prior partner negotiation. Of 20 women, 11 liked FemCap™ very much or somewhat; 7 considered it 'OK'; 2 disliked it. Best-liked attributes were comfort, discreet wear and reusability. Difficulties with removal abated over time. Qualitative data revealed a high value placed on lack of systemic side effects. Use of FemCap™ was feasible and acceptable, supporting expansion of research, particularly among relevant populations with unmet need.

[Ultrasonography as a method to determine the correct implantation of intratubaric devices]

BACKGROUND

Essure procedure consists in the placement of two coils in the intramural segment of Fallopian tubes by hysteroscopic causing a fibrosis reaction that unleashes a physiological obstruction. Hysterosalpingography, until today, is the gold standard checking the success of this method of sterilization.

OBJECTIVE

Determining if a scan at three months postimplantation is sufficient to confirm the correct positioning of the device.

MATERIAL AND METHODS

Descriptive study with 61 patients undergoing definitive hysteroscopic sterilization to validate transvaginal ultrasound as a technique to determine the effectiveness of the method.

RESULTS

There were placed 120 devices, of which 117 (97'5%) were visible by ultrasound. Comparing ultrasound findings with gold standard, we obtain that in cases of proper bilateral implantation by hysterosalpingography, with ultrasound we diagnosed the 81 '13%; in cases of correct unilateral implantation we detected 75% with ultrasound, except one patient who was considered proper placement of the coil by ultrasound but hysterosalpingography reported that it was misplaced and the Fallopian tube was permeable.

DISCUSSION

Transvaginal ultrasound is an appropriate method to confirm the correct position of intratubaric Essure devices, its safety, low cost and reproducibility. However, our study cannot replace the hysterosalpingography as gold standard.

[Tubal obstruction with an implant inserted by hysteroscopy: a report of 50 cases]

BACKGROUND

The Essure contraceptive device consists of a titanium and nickel coiled spring containing Dacron fibers. It is placed under hysteroscopic visualizaron in the proximal section of the Fallopian tube. The microinsert acts by inducing a tissue reaction that permanently blocks the tube within three months.

OBJECTIVE

Show our experience in the use and insertion of the Essure device, in a private office.

METHODS

We reviewed insertion procedure, complications, degree of tolerance and acceptance by user. Between June 2008 and May 2013 fifty cases with Essure placement were made in our office.

RESULTS

The average age was 36 years, as for the average number of pregnancies was two. The procedure time average was 6 minutes 25 seconds, no intraoperative complication was reported. All patients expressed very good tolerance and high degree of satisfaction with the procedure. A simple abdominal radiography was performed three months after the hysteroscopy to dem6nstrate the correct placement and position of the device, in all patients.

CONCLUSION

[corrected] The number of patients is enough to show the advantages of the method and the possibility of performing it in an ambulatory environment, as it can be a private office with the correct equipment to do it.

Potential for revitalisation of the diaphragm for family planning in Uganda: a rapid assessment of the feasibility of introducing the SILCS Diaphragm

This health systems assessment evaluated the feasibility of introducing a new contraceptive device, the SILCS single-size diaphragm, into the existing family planning method mix in Uganda. A total of 26 focus group discussions with 201 female and 77 male potential users and 98 key informant interviews with policymakers and providers were conducted between June and August 2010. Potential users, providers, and policymakers recognised that the SILCS Diaphragm could fill a gap in the method mix and expressed eagerness to make the SILCS Diaphragm available, particularly because it is nonhormonal and woman initiated. The diaphragm was viewed by all stakeholders as a method that would increase choice and could improve women's reproductive health in Uganda. Like many countries, Uganda's family planning programme is financially stretched, and clear support for the SILCS Diaphragm by end-users will need to be demonstrated before the product will be considered for public-sector introduction.

[Successful pregnancies outcomes with the use of in vitro fertilization after Essure® unilateral hydrossalpinx occlusion]

INTRODUCTION

Since two decades we witnessed the publication of several studies devoted to the study of the influence of the presence of hydrosalpinx on the results of embryo transfer techniques. The aim of this study is to present the results of treatment and pregnancy outcomes in women with a history of infertility associated with unilateral hydrosalpinx, visible on vaginal ultrasound, which were subjected to unilateral occlusion with Essure® and subsequent treatment with in vitro fertilization.

MATERIAL AND METHODS

We performed a prospective analysis of a sample of 6 women, with a history of infertility and unilateral hydrosalpinx, between April 2010 to May 2013. In all cases we proceeded to unilateral hysteroscopic placement of the Essure® microinsert, prior to performing a cycle for in vitro fertilization.

RESULTS

Of the 6 patients undergoing in vitro fertilization, 4 became pregnant (66.7%). Of these, two were uneventful pregnancies until delivery and 2 are still under surveillance, without complications. Of the patients who did not become pregnant after in vitro fertilization (n = 2, 33.3%), 1 conceived spontaneously during the subsequent monitoring.

DISCUSSION

The advancement of hysteroscopy in the treatment of hydrosalpinx using the Essure® microinsert placement is a valid alternative to the laparoscopic approach.

CONCLUSION

This study suggests the effectiveness of unilateral tubal occlusion caused by Essure® microinsert in improving outcomes of in vitro fertilization treatment in cases of infertility associated with unilateral hydrosalpinx, visible in the vaginal ultrasound.

Engineering a segmented dual-reservoir polyurethane intravaginal ring for simultaneous prevention of HIV transmission and unwanted pregnancy

The HIV/AIDS pandemic and its impact on women prompt the investigation of prevention strategies to interrupt sexual transmission of HIV. Long-acting drug delivery systems that simultaneously protect womenfrom sexual transmission of HIV and unwanted pregnancy could be important tools in combating the pandemic. We describe the design, in silico, in vitro and in vivo evaluation of a dual-reservoir intravaginal ring that delivers the HIV-1 reverse transcriptase inhibitor tenofovir and the contraceptive levonorgestrel for 90 days. Two polyether urethanes with two different hard segment volume fractions were used to make coaxial extruded reservoir segments with a 100 µm thick rate controlling membrane and a diameter of 5.5 mm that contain 1.3 wt% levonorgestrel. A new mechanistic diffusion model accurately described the levonorgestrel burst release in early time points and pseudo-steady state behavior at later time points. As previously described, tenofovir was formulated as a glycerol paste and filled into a hydrophilic polyurethane, hollow tube reservoir that was melt-sealed by induction welding. These tenofovir-eluting segments and 2 cm long coaxially extruded levonorgestrel eluting segments were joined by induction welding to form rings that released an average of 7.5 mg tenofovir and 21 µg levonorgestrel per day in vitro for 90 days. Levonorgestrel segments placed intravaginally in rabbits resulted in sustained, dose-dependent levels of levonorgestrel in plasma and cervical tissue for 90 days. Polyurethane caps placed between segments successfully prevented diffusion of levonorgestrel into the tenofovir-releasing segment during storage.Hydrated rings endured between 152 N and 354 N tensile load before failure during uniaxial extension testing. In summary, this system represents a significant advance in vaginal drug delivery technology, and is the first in a new class of long-acting multipurpose prevention drug delivery systems.

[Preparation and release mechanism of gestodene reservoir-type intravaginal rings]

This study taking gestodene (GEST) as a model, investigated the factors affecting reservoir-type intravaginal ring (IVR)'s drug release. This paper reported a gestodene intravaginal ring of reservoir design, comprising a gestodene silicone elastomer core encased in a non-medicated silicone sheath, separately manufactured by reaction injection moulding at 80 degrees C and heating vulcanization at 130 degrees C is reported. The test investigated the factors affecting drug release through a single variable method, taking the drug release rates of 21 days as standards. When changing the thickness of the controlling sheath outside, the ratio of the first day of drug release and mean daily release (MDR), named the relatively burst effect, is closing to 1 with the thickness of controlling sheath increasing, while the 1.25 mm sheath corresponding to 1.04 controlled the burst release effectively; a positive correlation (r = 0.992 2) existed between the average drug release (Q/t) and drug loading (A) within a certain range. The C6-165 controlling sheath with high solubility of GEST is easier to achieve controlled release of the drug; GEST crystalline power is more effective to implement controlled release of drugs among difficent states of the drug. A 1/4 fractional segment core gives a relatively burst effect of 1.76, while the 1/1 and 1/2 are 1.93 and 1.87 separately, at the same drug loading, concluding that use of a fractional segment core would allow development of a suitable GEST reservoir IVR. In summary, GEST reservoir-type IVR could be adjusted by the thickness of controlling sheath, the loading of drug, the material properties of controlling sheath, the dispersion state of drug, the additive composition and structure of intravaginal ring, to control the drug release behavior and achieve the desired drug release rate.

Lalloo D, Kamali A, Parkes-Ratanshi R. Pregnancy in HIV clinical trials in Sub Saharan Africa: failure of consent or contraception?

Objective

Higher than expected pregnancy rates have been observed in HIV related clinical trials in Sub-Saharan Africa. We designed a qualitative study to explore the factors contributing to high pregnancy rates among participants in two HIV clinical trials in Sub-Saharan Africa.

Methods

Female and male participants enrolled in one of two clinical HIV trials in south-west Uganda were approached. The trials were a phase III microbicide efficacy trial among HIV negative women using vaginal gel (MDP); and a trial of primary prevention prophylaxis for invasive cryptococcal disease using fluconazole among HIV infected men and women in Uganda (CRYPTOPRO). 14 focus group discussions and 8 in-depth interviews were conducted with HIV positive and negative women and their male partners over a six month period. Areas explored were their experiences about why and when one should get pregnant, factors affecting use of contraceptives, HIV status disclosure and trial product use.

Results

All respondents acknowledged being advised of the importance of avoiding pregnancy during the trial. Factors reported to contribute to pregnancy included; trust that the investigational product (oral capsules/vaginal gel) would not harm the baby, need for children, side effects that led to inconsistent contraceptive use, low acceptance of condom use among male partners. Attitudes towards getting pregnant are fluid within couples over time and the trials often last for more than a year. Researchers need to account for high pregnancy rates in their sample size calculations, and consider lesser used female initiated contraceptive options e.g. diaphragm or female condoms. In long clinical trials where there is a high fetal or maternal risk due to investigational product, researchers and ethics committees should consider a review of participants contraceptive needs/pregnancy desire review after a fixed period, as need for children, partners and health status of participants may alter over time.

Obesity and hormonal contraceptive efficacy

Obesity is a major public health concern affecting an increasing proportion of reproductive-aged women. Avoiding unintended pregnancy is of major importance, given the increased risks associated with pregnancy, but obesity may affect the efficacy of hormonal contraceptives by altering how these drugs are absorbed, distributed, metabolized or eliminated. Limited data suggest that long-acting, reversible contraceptives maintain excellent efficacy in obese women. Some studies demonstrating altered pharmacokinetic parameters and increased failure rates with combined oral contraceptives, the contraceptive patch and emergency contraceptive pills suggest decreased efficacy of these methods. It is unclear whether bariatric surgery affects hormonal contraceptive efficacy. Obese women should be offered the full range of contraceptive options, with counseling that balances the risks and benefits of each method, including the risk of unintended pregnancy.

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

BACKGROUND

A 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 DESIGN

Twenty 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.

RESULTS

Thirty-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.

CONCLUSIONS

A 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.

Contraception, venous thrombosis and biological plausability

Exogenous use of hormones leads to different impact on coagulation. Usually estrogen leads to an activation of coagulation, while use of progestogens alone do not. Combined oral contraceptives (COC) differs significantly regarding VTE risk depending on amount of estrogen and type of progestagen: COC containing desogestrol, gestoden or drospirenone in combination with ethinyl-estradiol (EE) (so called 3rd or 4th generation COC) are associated with a higher VTE risk than COC with EE and levonorgestrel or norethisterone (so called 2nd generation COC). The VTE risk for transdermal COC like vaginal ring (NuvaRing) or patch (Evra) is as high than than for COC of 3rd or 4th generation. 2nd generation COC should therefore be the first choice when prescribing hormonal contraception. Most PROGESTAGEN-only contraceptive methods do not increase VTE risk significantly. In patients with a history of venous thromboembolism (VTE) and /or a known thrombophilic defect COC are contraindicated, but progestagen-only contraceptives can be safely used in this patient group. New kinds of COC without EE but with Estradiolvalerat or Estradiol showed a much lower degree of coagulation activation than "classical" COC containing EE. If newer COC with Estradiolvalerat or Estradiol have a lower VTE risk, remains to be elucidated.

Contraceptive failures in overweight and obese combined hormonal contraceptive users

OBJECTIVE

To estimate weather contraceptive failure rates among combined oral contraceptive pill (OCP), patch, and vaginal ring users was associated with increasing body mass index (BMI).

METHODS

Females enrolled in a large contraceptive study offering the reversible method of their choice at no cost were followed-up for 2-3 years. We compared the failure rates (pregnancy) among users of the OCP, transdermal patch, and contraceptive vaginal ring stratified by BMI.

RESULTS

Among the 7,486 participants available for this analysis, 1,523 chose OCPs, patch, or ring at enrollment. Of the 334 unintended pregnancies, 128 were found to be a result of OCP, patch, or ring failure. Three-year failure rates were not different across BMI categories (BMI less than 25 8.44%, 95% confidence interval [CI] 6.1-11.5; BMI 25-30 11.03%, 95% CI 7.5-16.0; BMI more than 30 8.92%, 95% confidence interval 7.6-11.5). Increasing parity (hazard ratio [HR] 3.06, CI 1.31-7.18) and history of a previous unintended pregnancy (HR 2.82, CI 1.63-4.87), but not BMI, were significant risk factors for unintended pregnancy.

CONCLUSION

Overweight and obese females do not appear to be at increased risk for contraceptive failure when using the OCP, patch, or vaginal ring.

A modified SILCS contraceptive diaphragm for long-term controlled release of the HIV microbicide dapivirine

BACKGROUND

There is considerable interest in developing new multipurpose prevention technologies to address women's reproductive health needs. This study describes an innovative barrier contraceptive device--based on the SILCS diaphragm--that also provides long-term controlled release of the lead candidate anti-HIV microbicide dapivirine.

STUDY DESIGN

Diaphragm devices comprising various dapivirine-loaded polymer spring cores overmolded with a nonmedicated silicone elastomer sheath were fabricated by injection molding processes. In vitro release testing, thermal analysis and mechanical characterization were performed on the devices.

RESULTS

A diaphragm device containing a polyoxymethylene spring core loaded with 10% w/w dapivirine provided continuous and controlled release of dapivirine over a 6-month period, with a mean in vitro daily release rate of 174 mcg/day. The mechanical properties of the new diaphragm were closely matched to the SILCS diaphragm.

CONCLUSIONS

The study demonstrates proof of concept for a dapivirine-releasing diaphragm with daily release quantities potentially capable of preventing HIV transmission. In discontinuous clinical use, release of dapivirine may be readily extended over 1 or more years.

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

BACKGROUND

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.

PURPOSE

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.

METHODS

A PubMed search was conducted looking for the different trials, reviews and various guidelines relating to medical treatment of idiopathic HMB.

RESULTS

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.

CONCLUSION

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.