The combined contraceptive vaginal ring, NuvaRing: an international study of user acceptability

Exploring vaginal ring acceptability for contraception and sexually transmissible infection protection in India: a qualitative research study

Background New vaginal rings are being developed as single and multipurpose prevention technologies to protect women from pregnancy and/or sexually transmissible infections, such as HIV. Data on ring acceptability in low-resource settings is critical for new technologies to meet user needs.

METHODS

Women from slum and lower-income areas around Delhi, India, participated in focus group discussions on vaginal ring product perceptions and preferences. Participants were recruited based on following eligibility categories: age, marital status, contraceptive use, and number of children. The translated transcriptions of the qualitative data were analysed using a coding scheme generated from the areas of inquiry and relevant literature.

RESULTS

A total of 103 women from lower-middle-class or slum areas in Delhi participated in 13 focus group discussions between December 2012 and January 2013. Participants shared perceptions of vaginal ring product attributes, including size, colour, intended use (single indication or dual purpose), duration of use, side effects, biodegradability, and various preferences regarding product use, including access, use during sex, wear patterns, cleaning, and disposal. Participants also reflected on willingness to pay and male partner acceptability.

CONCLUSIONS

The results of this hypothetical acceptability study indicate that these low-income women in Delhi are: willing to try vaginal rings; unconcerned about wearing them during sex; very interested in protection from infections and unintended pregnancy; indifferent about colour of new rings; emphatic about being told that rings may change colour from menstrual blood staining; comfortable with thinner rings; willing to try thicker rings once familiar with thinner rings; in favour of starting with 1-month rings and then transitioning to longer-term rings; and in favour of first accessing rings at a facility and then managing resupply independently.

Characterization of anastrozole effects, delivered by an intravaginal ring in cynomolgus monkeys

STUDY QUESTION

Is it feasible to deliver anastrozole (ATZ), an aromatase inhibitor (AI), by a vaginal polymer-based drug delivery system in the cynomolgus monkey (Macaca fascicularis) to describe the pharmacokinetic profile?

SUMMARY ANSWER

The present study showed the effective release of ATZ into the systemic circulation from intravaginal rings in cynomolgus monkeys.

WHAT IS KNOWN ALREADY

ATZ is a marketed drug with well documented pharmacological and safety profiles for oral administration. Aromatase is the key enzyme catalyzing estrogen biosynthesis and is overexpressed in endometriotic lesions. AIs show therapeutic efficacy in endometriosis in exploratory clinical trials.

STUDY DESIGN, SIZE, DURATION

The pharmacokinetics of the in vivo release and the pharmacodynamic activity of ATZ released by intravaginal rings (IVR) were investigated in healthy cycling female cynomolgus monkeys in three different dose groups (n = 5) for one menstrual cycle.

PARTICIPANTS/MATERIALS, SETTING, METHODS

IVRs for the cynomolgus monkey, releasing three different doses of ATZ were designed and tested for in vitro/in vivo release for up to 42 days. For pharmacokinetic and pharmacodynamic evaluation, plasma samples were taken once daily from Day 1 to 3 and then every third day until menses occurred (17-42 days).

MAIN RESULTS AND THE ROLE OF CHANCE

ATZ was shown to be compatible with the IVR drug delivery system. An average in vivo release of 277 µg/day/animal of ATZ for one menstrual cycle was effective in causing a decrease of systemic estradiol (E₂) levels by ∼30% without inducing counter regulation such as the elevation of FSH or the formation of ovarian cysts.

LIMITATIONS, REASONS FOR CAUTION

The study was limited to three dose groups in which only the highest dose decreased the E₂ level. Hence, additional research with IVRs releasing higher amounts of ATZ is required to define the threshold for an ATZ-dependent ovarian stimulation in cynomolgus monkeys.

WIDER IMPLICATIONS OF THE FINDINGS

The release rate administered from IVRs is sufficient and in a range that supports feasibility of IVR administration of ATZ as a new approach for long-term therapy of estrogen-dependent diseases such as endometriosis in human.

Risk drinking and contraception effectiveness among college women

Risk drinking, especially binge drinking, and unprotected sex may co-occur in college women and increase the risks of STI exposure and pregnancy, but the relationships among these behaviors are incompletely understood. A survey was administered to 2012 women of ages 18-24 enrolled in a public urban university. One-quarter of the college women (23%) drank eight or more drinks per week on average, and 63% binged in the past 90 days, with 64% meeting criteria for risk drinking. Nearly all sexually active women used some form of contraception (94%), but 18% used their method ineffectively and were potentially at risk for pregnancy. Forty-four percent were potentially at risk for STIs due to ineffective or absent condom usage. Ineffective contraception odds were increased by the use of barrier methods of contraception, reliance on a partner's decision to use contraception, and risk drinking, but were decreased by the use of barrier with hormonal contraception, being White, and later age to initiate contraception. In contrast, ineffective condom use was increased by reliance on a partner's decision to use condoms, the use of condoms for STI prevention only, and by risk drinking. Thirteen percent of university women were risk drinkers and using ineffective contraception, and 31% were risk drinkers and failing to use condoms consistently. Risk drinking is related to ineffective contraception and condom use. Colleges should promote effective contraception and condom use for STI prevention and consider coordinating their programs to reduce drinking with programs for reproductive health. Emphasizing the use of condoms for both pregnancy prevention and STI prevention may maximize women's interest in using them.

What do portuguese women prefer regarding vaginal products? Results from a cross-sectional web-based survey

Therapeutic outcomes of vaginal products depend not only on their ability to deliver drugs to or through the vagina but also on acceptability and correct use. Women's preferences, in turn, may vary according to age and cultural backgrounds. In this work, an anonymous online survey was completed by 2529 Portuguese women to assess their preferences for physical characteristics and mode of application of vaginal products, according to age. Additionally, intention to use and misconceptions about these issues were assessed. The majority of women of all age groups would use vaginal products to treat or prevent diseases, upon medical prescription. Women preferred vaginal products to be odorless and colorless gels, creams and ointments composed by natural origin drugs/excipients and applied by means of an applicator. Although the majority of women would prefer not to insert any product in the vagina, intention to use for self and recommendation to use for others was associated with previous experiences with vaginal products. General concerns and misconceptions related to use of vaginal products were rare. These data may contribute to the development of products that women are more prone to use.

Acceptability of the Nestorone®/ethinyl estradiol contraceptive vaginal ring: development of a model; implications for introduction

OBJECTIVES

Develop and test a theoretical acceptability model for the Nestorone®/ethinyl estradiol contraceptive vaginal ring (CVR); explore whether domains of use within the model predict satisfaction, method adherence and CVR continuation.

STUDY DESIGN

Four domains of use were considered relative to outcome markers of acceptability, that is, method satisfaction, adherence and continuation. A questionnaire to evaluate subjects' experiences relative to the domains, their satisfaction (Likert scale) and adherence to instructions for use was developed and administered to 1036 women enrolled in a 13-cycle Phase 3 trial. Method continuation was documented from the trial database. Stepwise logistic regression (LR) analysis was conducted and odds ratios (ORs) calculated to assess associations of satisfaction with questions from the four domains. Fisher's Exact Test was used to determine the association of satisfaction with outcome measures.

RESULTS

A final acceptability model was developed based on the following determinants of CVR satisfaction: ease of use, side effects, expulsions/feeling the CVR and sexual activity including physical effects during intercourse. Satisfaction was high (89%) and related to higher method adherence [OR, 2.6 (1.3, 5.2)] and continuation [OR, 5.5 (3.5, 8.4)]. According to the LR analysis, attributes of CVR use representing items from the four domains - finding it easy to remove, not complaining of side effects, not feeling the CVR while wearing it and experiencing no change or an increase in sexual pleasure and/or frequency - were associated with higher odds of satisfaction.

CONCLUSION

Hypothesized domains of CVR use were related to satisfaction, which was associated with adherence and continuation. Results provide a scientific basis for introduction and future research.

IMPLICATIONS STATEMENT

Acceptability research is important when introducing a new method of contraception and determining whether it can be a successful option in meeting the reproductive health needs of women and men. This study was designed to test a conceptual model of acceptability and identify factors associated with successful use of a new contraceptive delivery modality. Original research was conducted for this publication.

Quality of sexual life of women using the contraceptive vaginal ring in extended cycles: preliminary report

OBJECTIVE

To evaluate the quality of the sexual life of healthy women who are using a contraceptive vaginal ring (CVR) in extended cycles.

METHODS

Fifty-two women (18 to 32 years old) seeking hormonal contraception were enrolled in this prospective study. Women were to use a CVR releasing daily 15 μg of ethinylestradiol (EE) and 120 μg of etonogestrel (ENG) for 63 days, followed by a four-day hormone-free interval, for two such extended cycles. At baseline and at the first (day 63-73) and second (day 126-134) follow-ups the Female Sexual Function Index (FSFI) and the Short Form-36 (SF-36) questionnaires were administered to investigate, respectively, sexual behaviour and the quality of life (QoL). The Female Sexual Distress Scale (FSDS) was used to verify whether sexual dysfunction caused significant personal distress to the woman.

RESULTS

The FSFI and FSDS scores obtained at the first and second follow-up appointments detected an improvement with respect to the baseline score (p < 0.05). QoL measures of body pain, general health and emotional role improved at the first follow-up visit (p < 0.05); at the second one, all variables showed improvement (p < 0.05).

CONCLUSION

According to these preliminary data the CVR in extended cycles could improve the sexual function and the QoL of women.

User's acceptability of OvuSense: a novel vaginal temperature sensor for prediction of the fertile period

Measuring changes in core body temperature provides a valid method to detect ovulation and increase fertility. 'OvuSense' is a novel vaginal sensor that can predict the fertility window by recording and analysing the changes in intravaginal temperature records. This study aimed to determine patients 'acceptability and satisfaction after using OvuSense'. We approached 13 women to complete a patient satisfaction survey after using OvuSense in a prospective, longitudinal, comparative study, to test its validity and accuracy in detecting ovulation over a minimum period of three cycles. All 13 women agreed to participate in this survey. The majority of the participants found the usage of the reader to be very easy; 76.9% of the women said it was extremely comfortable to use the device during the night and 76.9% found the idea of using the intravaginal reader to be very convenient. Overall, 69.2% of women were extremely satisfied using the device. The idea of detecting intravaginal core body temperature changes appears to be highly acceptable by women.

Multicenter Study of Contraceptive Vaginal Ring (NuvaRing(®)) in Normal Daily Practice in Indian Women

OBJECTIVE

This was the first Indian multicenter study at six specialty hospitals, to assess the real-life usage of the vaginal ring in daily clinical practice.

METHODS

This open-label, prospective, single-arm, nonrandomized, interventional study enrolled 252 women aged >18 years, seeking contraception with no contraindications to the use of combined hormonal contraceptive. Women were provided the ring with a monthly follow-up schedule for three cycles. Cycle control, acceptability, tolerability, and safety assessments were recorded at each visit.

RESULTS

Regular menstrual bleeding was reported by 76.2 % (192/252) at baseline. In study completers, regular bleeding was seen in 94.1 % (192/204), 97.5 % (199/204), and 98 % (200/204) in the 1st, the 2nd, and the 3rd cycles, respectively. Most (94.2 % [195/207]) women were very satisfied or satisfied with the ring, and 93.2 % (193/207) would recommend it to others. No pregnancies or serious adverse events were reported.

CONCLUSION

The study demonstrated that NuvaRing(®) is a highly effective contraceptive method with an excellent cycle control. It is well tolerated and accepted by Indian women.

Counseling on vaginal delivery of contraceptive hormones: implications for women's body knowledge and sexual health

BACKGROUND

Healthcare providers (HCPs) have an important role in helping women select the contraceptive method that best matches their needs and lifestyle. Recent surveys outline the need of women to be informed about all available choices, including the newest methods (particularly those not requiring daily administration), such as vaginal contraception.

METHODS

The most relevant publications on combined contraceptive vaginal ring are revised in the context of counseling as an opportunity to empower women in term of vaginal health and sexual functioning.

RESULTS

HCPs should explain the main characteristics of the combined contraceptive vaginal ring including the anatomical and physiological implications that make the vagina an ideal route of hormonal administration and the basic notions about functional modifications of the vagina during reproductive life. Clinical data on the vaginal ring should be summarized with regard to efficacy, tolerability, pharmacokinetics, cycle control and user acceptability, including recent findings on extra-contraceptive benefits (also compared to other hormonal contraceptives) on the vaginal flora and on sexual function.

CONCLUSION

Vaginal contraception offers various benefits and should always be discussed during contraceptive counseling. An open dialogue about vaginal contraception will also help enhance body knowledge and sexual health.

Development of dapivirine vaginal ring for HIV prevention

In the continuing effort to develop effective HIV prevention methods for women, a vaginal ring containing the non-nucleoside reverse transcriptase inhibitor dapivirine is currently being tested in two safety and efficacy trials. This paper reviews dapivirine ring's pipeline development process, including efforts to determine safe and effective dosing levels as well as identify delivery platforms with the greatest likelihood of success for correct and consistent use. Dapivirine gel and other formulations were developed and tested in preclinical and clinical studies. Multiple vaginal ring prototypes were also tested, resulting in the current ring design as well as additional designs under consideration for future testing. Efficacy results from clinical trials are expected in 2015. Through ongoing consultations with national regulatory authorities, licensure requirements for dapivirine vaginal ring approval have been defined. This article is based on a presentation at the "Product Development Workshop 2013: HIV and Multipurpose Prevention Technologies," held in Arlington, Virginia on February 21-22, 2013. It forms part of a special supplement to Antiviral Research.

Multipurpose prevention technologies: products in development

Multipurpose prevention technologies (MPTs) are broadly defined as products capable of simultaneously addressing multiple sexual and reproductive health needs including unintended pregnancy, STIs including HIV-1, and other reproductive tract infections. MPTs have been discussed for a few decades but little product development has occurred. With the recent proof-of-concept that a topically applied antiretroviral (ARV) can effectively reduce sexual transmission of HIV-1 (tenofovir 1% gel) the impetus to develop MPTs is gaining momentum. Products currently in development are broadly categorized as either long-acting or on-demand. Long-acting MPTs include intravaginal rings (IVRs) and long-acting injectable products. Several IVR MPTs are under development including one designed to release tenofovir to prevent transmission of HIV-1 and levonorgestrel (LNG) to prevent unintended pregnancy over a 90-day period. Another MPT IVR under development is designed to release the ARV dapivirine and LNG for 2 months. Long-acting injectable pre-exposure prophylaxis (PrEP) formulations of rilpivirine (TMC278) and GSK1265744 have entered clinical evaluation and could form the basis of long-acting injectable products for HIV-1 prevention and prevention of unintended pregnancy. On-demand products include TFV 1% gel (HIV-1/HSV-2 prevention), a zinc/carrageenan zinc gel (HIV-1/HSV-2 prevention), and the SILCS diaphragm administered with TFV 1% gel. Significant technical, funding, and regulatory hurdles must be overcome to develop most MPTs; however, the significant reproductive health benefits to many women around the world should provide motivation to overcome these hurdles. This article is based on a presentation at the "Product Development Workshop 2013: HIV and Multipurpose Prevention Technologies", held in Arlington, Virginia on February 21-22, 2013. It forms part of a special supplement to Antiviral Research.

Clinical use of vaginal or rectally applied microbicides in patients suffering from HIV/AIDS

Microbicides, primarily used as topical pre-exposure prophylaxis, have been proposed to prevent sexual transmission of HIV. This review covers the trends and challenges in the development of safe and effective microbicides to prevent sexual transmission of HIV Initial phases of microbicide development used such surfactants as nonoxynol-9 (N-9), C13G, and sodium lauryl sulfate, aiming to inactivate the virus. Clinical trials of microbicides based on N-9 and C31G failed to inhibit sexual transmission of HIV. On the contrary, N-9 enhanced susceptibility to sexual transmission of HIV-1. Subsequently, microbicides based on polyanions and a variety of other compounds that inhibit the binding, fusion, or entry of virus to the host cells were evaluated for their efficacy in different clinical setups. Most of these trials failed to show either safety or efficacy for prevention of HIV transmission. The next phase of microbicide development involved antiretroviral drugs. Microbicide in the form of 1% tenofovir vaginal gel when tested in a Phase IIb trial (CAPRISA 004) in a coitally dependent manner revealed that tenofovir gel users were 39% less likely to become HIV-infected compared to placebo control. However, in another trial (VOICE MTN 003), tenofovir gel used once daily in a coitally independent mode failed to show any efficacy to prevent HIV infection. Tenofovir gel is currently in a Phase III safety and efficacy trial in South Africa (FACTS 001) employing a coitally dependent dosing regimen. Further, long-acting microbicide-delivery systems (vaginal ring) for slow release of such antiretroviral drugs as dapivirine are also undergoing clinical trials. Discovering new markers as correlates of protective efficacy, novel long-acting delivery systems with improved adherence in the use of microbicides, discovering new compounds effective against a broad spectrum of HIV strains, developing multipurpose technologies incorporating additional features of efficacy against other sexually transmitted infections, and contraception will help in moving the field of microbicide development forward.

Intravaginal rings as delivery systems for microbicides and multipurpose prevention technologies

There is a renewed interest in delivering pharmaceutical products via intravaginal rings (IVRs). IVRs are flexible torus-shaped drug delivery systems that can be easily inserted and removed by the woman and that provide both sustained and controlled drug release, lasting for several weeks to several months. In terms of women's health care products, it has been established that IVRs effectively deliver contraceptive steroids and steroids for the treatment of postmenopausal vaginal atrophy. A novel application for IVRs is the delivery of antiretroviral drugs for the prevention of human immunodeficiency virus (HIV) genital infection. Microbicides are antiviral drugs delivered topically for HIV prevention. Recent reviews of microbicide IVRs have focused on technologies in development and optimizing ring design. IVRs have several advantages, including the ability to deliver sustained drug doses for long periods of time while bypassing first pass metabolism in the gut. IVRs are discreet, woman-controlled, and do not require a trained provider for placement or fitting. Previous data support that women and their male sexual partners find IVRs highly acceptable. Multipurpose prevention technology (MPT) products provide protection against unintended/mistimed pregnancy and reproductive tract infections, including HIV. Several MPT IVRs are currently in development. Early clinical testing of new microbicide and MPT IVRs will require a focus on safety, pharmacokinetics and pharmacodynamics. Specifically, IVRs will have to deliver tissue concentrations of drugs that are pharmacodynamically active, do not cause mucosal alterations or inflammation, and do not change the resident microbiota. The emergence of resistance to antiretrovirals will need to be investigated. IVRs should not disrupt intercourse or have high rates of expulsion. Herein, we reviewed the microbicide and MPT IVRs currently in development, with a focus on the clinical aspects of IVR assessment and the challenges facing microbicide and MPT IVR product development, clinical testing, and implementation. The information in this review was drawn from PubMed searches and a recent microbicide/MPT product development workshop organized by CONRAD.

Vaginal health in contraceptive vaginal ring users - A review

BACKGROUND

To provide an overview of the available data from clinical studies of vaginal conditions in women who use a vaginal ring as a contraceptive.

METHODS

A systematic review of the literature.

RESULTS

Millions of women have already used the ethylene vinyl acetate vaginal ring that releases ethinylestradiol and etonogestrel for contraception. Because of its small size, more than four out of five women using the ring report that they do not feel it, even during sexual intercourse. No colposcopic or cytological changes have been observed in users, although approximately 10% have increased vaginal discharge. While in vitro studies have shown adhesion of Candida yeasts to the vaginal ring surface, clinical studies have not demonstrated a greater incidence of Candida infections compared to users of equivalent oral contraceptives. Some clinical studies suggest a lower incidence of bacterial vaginosis. No interaction exists between concomitant use of the vaginal ring and other drugs or products for vaginal use.

CONCLUSION

The use of a contraceptive vaginal ring does not alter the vaginal ecosystem and therefore does not substantially affect vaginal health.

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.

Microbicide dosage forms

Microbicides are topically applied, user controlled dosage forms that are being developed to prevent the transmission of HIV during coitus. Early candidates focused on coitally dependent dosage forms such as gels and creams. More recent development has focused on broadening the coitally dependent options through the introduction of films and fast dissolving tablets. Additionally, it has become important to have longer acting products to minimize the burden of user compliance and thus vaginal rings have been developed providing sustained delivery of antiretroviral drugs. This chapter discusses the history of microbicides along with a detailed description of coitally dependent products, gels, films, tablets diaphragms, as well as coitally independent dosage forms such as vaginal rings and the introduction of a new technology, electrospun fibers.

What's good and bad about contraceptive products?: a best-worst attribute experiment comparing the values of women consumers and GPs

BACKGROUND

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.

OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Current status of contraceptive vaginal rings

Contraceptive vaginal rings (CVR) offer a new, effective contraceptive option, expanding the available choices of hormonal contraception. Various ring prototypes have been evaluated: progestin-only rings and combined progestin-estrogen rings, as well as different combination of progestins and estrogens. The progestin-only ring is intended for continuous use, whereas the combined ring has been designed for cyclic 3-week in/1-week out use, although several studies have explored alternative schemes of extended use. However, only two ring designs have reached the market: NuvaRing, a 1-month combined ring that releases etonogestrel and ethinylestradiol, and Progering, a 3-month progesterone-releasing ring for use in lactating women. A one year Nestorone/ethinyl estradiol CVR is approaching the final stages of development, as the Population Council is preparing to submit a new drug application to the Food and Drug Administration. The main advantages of CVRs are their effectiveness (similar or slightly better than the pill), ease of use without the need of remembering a daily routine, user ability to control initiation and discontinuation, nearly constant release rate allowing for lower doses, greater bioavailability and good cycle control with the combined ring, in comparison with oral contraceptives. Current prototypes in development include rings releasing progesterone receptor modulators, which would provide estrogen-free contraception, as well as combined rings releasing estradiol, instead of ethinyl-estradiol, providing a safer profile. Furthermore, intensive efforts towards developing dual protection rings, providing both contraception and protection against reproductive tract infections, offer hope that this greatly needed technology will soon undergo clinical testing and will be in the hands of women worldwide in the near future.

High acceptability of a vaginal ring intended as a microbicide delivery method for HIV prevention in African women

Vaginal rings (VRs) are new methods for continuous delivery of microbicides. This is the first study to quantitatively and qualitatively explore the acceptability of rings in Africa: 157 HIV-negative, sexually active women aged 18-35 used a placebo silicone elastomer ring for 12 weeks. They completed product acceptability questionnaires every 4 weeks. We conducted 6 exit focus group discussions with a subset of 48 women and 19 in-depth interviews with male partners. Retention in the study was high (97 %). Initial insertion at the clinic was successful on first attempt for 81 % of participants. Most women were comfortable using the ring, and very few (≤2 %) could feel it during daily activities or had ring-related physical or emotional problems. In the qualitative interviews many participants reported that they initially had concerns about using the ring. However, only a minority of women actually reported concerns with the ring during the study. The most frequent concern was that the ring would get lost inside the body (20 %), and this was significantly correlated with study site, frequently thinking about the ring and reporting that the ring was not very easy to remove. Qualitative data suggest that informants grew to like the ring because it felt securely placed, was unnoticeable during daily activities, and felt "normal" during sex. The ring appeared to be highly acceptable for women and men. Initial concerns with this novel method suggest a need for enhanced product counseling when VRs are introduced.

Vaginal ring adherence in sub-Saharan Africa: expulsion, removal, and perfect use

In sub-Saharan Africa, HIV incidence and prevalence remain disproportionately high among women. Vaginal rings (VRs) have been formulated for the delivery of antiretroviral-based microbicides, and their favorable safety and tolerability profiles reported in clinical studies. Although the concept of drug release through a VR has existed since 1970, and VRs have been marketed since 1992 for contraceptive or hormone replacement purposes, VR use as a microbicide delivery system is a novel application. This is the first study to evaluate VR adherence among African women in the context of its potential use as an HIV prevention method, to examine predictors of adherence, and to describe clinical or contextual reasons for VR removals or nonadherence. This was a randomized trial of the safety and acceptability of a placebo VR worn for 12 weeks in 170 HIV-negative, African women aged 18-35 in four clinic sites in South Africa and Tanzania. The findings suggest that adherence to VR use in the context of HIV prevention trials in these communities should be high, thereby enabling more accurate assessment of an active microbicide safety and efficacy.

Quantitative evaluation of a hydrophilic matrix intravaginal ring for the sustained delivery of tenofovir

In vitro testing and quantitative analysis of a matrix, hydrophilic polyether urethane (HPEU) intravaginal ring (IVR) for sustained delivery of the anti-HIV agent tenofovir (TFV) are described. To aid in device design, we employed a pseudo-steady-state diffusion model to describe drug release, as well as an elastic mechanical model for ring compression to predict mechanical properties. TFV-HPEU IVRs of varying sizes and drug loadings were fabricated by hot-melt extrusion and injection molding. In vitro release rates of TFV were measured at 37 °C and pH 4.2 for 30 or 90 days, during which times IVR mechanical properties and swelling kinetics were monitored. Experimental data for drug release and mechanical properties were compared to model predictions. IVRs loaded with 21% TFV (w/w) released greater than 2mg TFV per day for 90 days. The diffusion model predicted 90 day release data by extrapolating forward from the first 7 days of data. Mechanical properties of IVRs were similar to NuvaRing, although the matrix elastic modulus decreased up to three-fold following hydration. This is the first vaginal dosage form to provide sustained delivery of milligram quantities of TFV for 90 days. Drug release and mechanical properties were approximated by analytical models, which may prove useful for the continuing development of IVRs for HIV prevention or other women's health indications.

Future strategies in microbicide development

The reduction in human immunodeficiency virus (HIV) infection in women demonstrated by pericoital use of tenofovir gel has encouraged the continued development of microbicides. Novel approaches include new ways to deliver tenofovir, as well as products that contain different antiretroviral drugs, either as single agents or as combinations of antiretroviral drugs. Indeed, emphasis has renewed on the development of multipurpose prevention technologies, products designed to address multiple sexually transmitted infections. Dual-purpose contraceptive antiretroviral products are also being designed to prevent HIV and pregnancy. Since consistent and correct use of these products will be critical to their effectiveness, the active pharmaceutical ingredients must be delivered in acceptable vaginal dosage forms, such as gels, films and sustained-release vaginal rings. The development of different dosage forms will help ensure that women can find a method to protect themselves from HIV, pregnancy, and potentially other sexually transmitted infections.

Drug delivery in multiple indication (multipurpose) prevention technologies: systems to prevent HIV-1 transmission and unintended pregnancies or HSV-2 transmission

INTRODUCTION

The development of multiple indication (multipurpose) prevention technologies (MIPTs) is driven by overlapping relationships in the area of female reproductive health.

AREAS COVERED

In this review, the basis for MIPTs is detailed. The current state of the field for the use of drug delivery in novel MIPTs is covered. Of particular interest is the application of intravaginal rings (IVRs) for the delivery of two drugs simultaneously, to prevent one STI and pregnancy, or two STIs. IVRs are currently available commercially for contraception and have been developed for release of microbicides to prevent sexual transmission of HIV-1. Novel IVRs capable of releasing relatively large amounts of drugs such as tenofovir are discussed, along with those that contain independent delivery elements, such as pods, that can be used to release drugs at independent rates. The vaginal administration of macromolecules (antibodies and vaccines) is also reviewed in the context of MIPTs.

EXPERT OPINION

The field of MIPTs remains one of potential. There is yet to be a proven microbicide effective at preventing sexual transmission of HIV-1. Development of MIPTs in the near term will proceed under the assumption that one or more antiretroviral (ARV) drugs will eventually be proven successful. IVRs have already demonstrated success in the area of contraception. Prevention of sexual transmission of HIV-1 and herpes simplex virus-2 (HSV-2) (or suppression of recurrence) remains an attractive MIPT target. In the long term, development of MIPTs will require validation of surrogate end points, particularly for prevention of HIV-1 transmission.

Treatment satisfaction instruments for different purposes during a product's lifecycle: keeping the end in mind

This review investigates whether the development and implementation of treatment satisfaction instruments during a product's lifecycle are informed by their purpose. A basic literature review was performed between 2000 and 2010 using electronic databases (PubMed, PsycINFO®, and EMBASE) and the keywords 'satisfaction' and 'questionnaire' and 'medication' or 'drug'. Relevant articles were reviewed to extract the following information: type of study; study objectives; treatment satisfaction instrument used; clinical condition/indication; purpose of instrument; development of instrument; association of satisfaction with other endpoint measures; and main results and conclusions. Of 875 abstracts, 80 articles were further considered. Treatment satisfaction instruments were most commonly used in observational studies and interventional clinical trials. The review indicated similarities regarding the development and validation of satisfaction instruments, such as using patient input to derive the items and exploring classical measurement properties specific to the target population. Although some differences were apparent between instruments intended for use in clinical trials and clinical practice (e.g. the approaches used to enable the interpretation of satisfaction scores), the specificities of the implementation of treatment satisfaction during a product's lifecycle were rarely considered. By 'keeping the end in mind', data from treatment satisfaction instruments can help at three key stages: (i) product access to market: generating evidence as part of an overall value proposition to facilitate product reimbursement at a national level; (ii) market access to product: making the product available at a local level (e.g. local hospital formularies); and (iii) clinical practice: enhancing market penetration and product expansion after launch, and demonstrating value for prescribers. Furthermore, the development, validation, and interpretation of scores from treatment satisfaction instruments should be sensitive to the intended purpose. By considering the stage in the product lifecycle when an instrument is to be used, treatment satisfaction instruments can be developed with the specific research purpose and target audience in mind - whether it be patients, payers, or prescribers. In the future, treatment satisfaction instruments will become increasingly important for informing decisions at the individual level, giving patients a voice towards their overall management and care, and enhancing the relationship between doctor and patient.

Preferences for new and existing contraceptive products

New contraceptive methods provide greater choice in terms of effectiveness, management of side-effects, convenience and frequency of administration and flexibility, but make the decisions about contraception more complex. There are limited data on the factors that determine women's choices among these alternatives, to inform providers about the factors which are most important to women, or to predict uptake of new products. This paper reports on a choice experiment designed to elicit women's preferences in relation to prescribed contraception and to forecast the impact of the introduction of two new products into the Australian market. A generalised multinomial logit model is estimated and used in the simulation exercise. The model forecasts that the hormonal patch would be well received among women, achieving a greater market share than current non-pill products, but the vaginal ring would have limited appeal.

Acceptability of the vaginal contraceptive ring among adolescent women

STUDY OBJECTIVE

Although underutilized, the vaginal contraceptive ring has several advantages over other contraceptive methods that could benefit adolescents. We examined factors that may influence willingness to try the vaginal ring including: sexual and contraceptive history, genital comfort, and vaginal ring characteristics.

DESIGN

Cross sectional

SETTING

Midwestern adolescent health clinics

PARTICIPANTS

Adolescent women (N = 200; 14-18 years; 89% African-American) INTERVENTIONS/MAIN OUTCOME MEASURES: All participants received education about the vaginal ring and viewed pictures demonstrating insertion; they then completed a visual/audio computer-assisted self interview. The primary outcome variable, willingness to try the vaginal ring, was a single Likert-scale item.

RESULTS

Over half the participants reported knowledge of the vaginal ring with healthcare providers identified as the most important source of contraceptive information. Comfort with one's genitals, insertion and removal, using alternative methods of insertion, and knowing positive method characteristics were significantly associated with willingness to try the vaginal ring. A decreased willingness to try the vaginal ring was related to concerns of the ring getting lost inside or falling out of the vagina.

CONCLUSIONS

Willingness to try the ring was associated with positive feelings about genitals (e.g., comfort with appearance, hygiene, function). Thus, to increase willingness to try the vaginal ring among adolescents, providers should make it common practice to discuss basic female reproductive anatomy, raise awareness about female genital health and address concerns about their genitals. Providers can offer alternative insertion techniques (e.g., gloves) to make use more accessible. These strategies may increase vaginal ring use among adolescents.

Matched-pairs analysis of ovarian suppression during oral vs. vaginal hormonal contraceptive use

BACKGROUND

This study was conducted to compare ovarian suppression during oral vs. vaginal hormonal contraceptive use. Secondary aims included comparison of endometrial thickness and bleeding patterns.

METHODS

In two open-label trials assessing ovarian suppression, 33 compliant women completed both studies. They first used oral contraceptive pills (OCs) [randomized to either 20 mcg ethinyl estradiol (EE)/100 mcg levonorgestrel (LNG) or 30 mcg EE/150 mcg LNG] and subsequently used contraceptive vaginal rings (CVRs) (daily release of 15 mcg EE/120 mcg etonogestrel), all 21/7-day regimens. Participants had at least one run-in cycle using each contraceptive method prior to evaluation. During one cycle of each method, women underwent biweekly transvaginal sonography to measure ovarian follicular diameters and endometrial thickness. We also noted presence of a corpus luteum or a ruptured follicle as a marker of ovulation. Participants recorded bleeding days on paper calendars. We used matched-pairs analyses as appropriate.

RESULTS

During follow-up, we identified at least one ovarian follicle ≥8 mm in 20/33 (61%) OC users and 12/33 (36%) CVR users (matched-pairs analysis, p=.02). Similar trends were seen for larger follicles; however, we had limited statistical power to evaluate these differences. Median follicular diameter among OC users was larger than median follicular diameter among CVR users (p=.01). We did not observe a corpus luteum or ruptured follicle in any participant during either study. Endometrial thickness was similar during OC and CVR use (mean 4.1±1.4 vs. 4.1±1.6 mm, p=.9), as was the number of bleeding or spotting days (mean 2.1±2.4 vs. 1.9±2.1, p=.8). Oral contraceptive pill dose was unrelated to follicle diameter, endometrial thickness or bleeding.

CONCLUSIONS

Ovarian follicles ≥8 mm were more common in 33 compliant women during OC use than during CVR use, indicating that CVR use results in greater ovarian suppression than OC use.

Examining the efficacy, safety, and patient acceptability of the combined contraceptive vaginal ring (NuvaRing)

The contraceptive vaginal ring is a novel contraceptive method that offers unique advantages. Intravaginal delivery of both estrogen and progesterone allows continuous release of medication, resulting in lower systemic levels. The use of long-term combined hormonal contraception enables improved cycle control compared with progesterone-only methods. The indications and usage of the NuvaRing^® are described along with the efficacy, tolerability, and safety. Overall, the contraceptive vaginal ring appears to be very effective, with a favorable side-effect profile, and is highly acceptable to most patients.

Mathematical modeling of drug delivery from torus-shaped single-layer devices

A mathematical modeling of controlled release of drug from torus-shaped single-layer devices is presented. Analytical solutions based on the pseudo-steady state approximation are derived. The reliability and usefulness of the model are ascertained by comparison of the simulation results with matrix-type vaginal ring experimental release data reported in the literature. A good agreement between the model prediction and the experimental data is observed. An analysis of the effect of the variation in torus design parameters on the solute release is also presented. The model is applicable only to torus-shaped single-layer systems wherein the initial load of drug is higher than its solubility in the polymer.

Cerebral venous sinus thrombosis in a woman using the etonogestrel-ethinyl estradiol vaginal contraceptive ring: a case report

BACKGROUND

The vaginal contraceptive ring is a hormonal contraceptive that releases etonogestrel and ethinyl estradiol. Cerebral venous sinus thrombosis (CVST) is a rare but serious complication of hormonal contraceptive use.

CASE

We present a case of CVST in a 33-year-old nulligravid woman who was using a vaginal contraceptive ring. At the time of presentation, she had been using the ring for 18 months, having previously used oral contraceptives for 13 years. She had no additional risk factors for thrombosis apart from cigarette smoking. Despite vigorous management, the patient died from the effects of the CVST.

CONCLUSION

The serious adverse effects of the vaginal contraceptive ring are not well known, although deep vein thrombosis, pulmonary embolism, and aortic thrombosis in association with use of the ring have been reported to Health Canada. Continuing post-market surveillance of thrombotic risk in users of the vaginal contraceptive ring is critical.

Contraception for adolescents with lupus

Sexually active adolescents, including young women with lupus, are at high risk for unplanned pregnancy. Unplanned pregnancy among teens with lupus is associated with an elevated risk of poor maternal and fetal outcomes. The provision of effective contraception is a crucial element of care for a sexually-active young woman with lupus. Unfortunately, providers may be hesitant to prescribe contraception to this group due to concerns about increasing the risk of lupus complications. This article reviews the risks and benefits of currently-available contraceptives for young women with lupus. Providers are encouraged to consider long-term, highly-effective contraception, such as implantables and intrauterine devices, for appropriately selected adolescents with lupus.

[General practitioners' (GPs) practice regarding the line to take in case of missed pill]

OBJECTIVE

To explore general practitioners' (GPs) practice face of missed pill and prevention of such missings.

MATERIAL AND METHOD

Twenty-five GPs from Sarthe Department (Western France) took part in semistructured interview during which they expressed themselves on the prevention of missed pill and its consequences.

RESULTS

Twelve out of 20 physicians stated positively that their female patients often forget their pill. However, they noted that missed pill was seldom a reason for phone call or consultation. During the initial pill prescription, GPs insisted on how to take the pill (14/25) as well as advice in case of a missed pill (22/25), their availability (12/25) and the instruction leaflet (16/25). But only five quoted the importance of involving women in the choice of contraception. On prescription renewal, only nine out of 25 ask their patients about observance defect and eight out of 25 repeated the information. If patients asked for further explanation, only two doctors out of 25 had practices in line with the French National Authority for Health's (HAS) recommandation guidelines.

CONCLUSION

GPs' attitudes are partly due to a lack of practice's knowledge in primary and emergency contraception methods. It seems essential to promote GPs' training and to take into account their expectations and needs. Furthermore, female patient must be actor of the choice of her contraceptive method in order to improve compliance and, therefore, effectiveness.

Development of topical microbicides to prevent the sexual transmission of HIV

Women comprise almost 50% of the population of people living with HIV and the majority of these women contracted the virus through sexual transmission in monogamous relationships in the developing world. In these environments, where women are not empowered to protect themselves through the negotiation of condom use, effective means of preventing HIV transmission are urgently needed. In the absence of an approved and effective vaccine, microbicides have become the strategy of choice to provide women with the ability to prevent HIV transmission from their infected partners. Topical microbicides are agents specifically developed and formulated for use in either the vaginal or rectal environment that prevent infection by sexually transmitted infectious organisms, including pathogenic viruses, bacteria and fungi. Although a microbicidal product will have many of the same properties as other anti-infective agents and would be similarly developed through human clinical trials, microbicide development bears its own challenges related to formulation and delivery and the unique environment in which the product must act, as well as the requirement to develop a product that is acceptable to the user. Herein, perspectives based on preclinical and clinical microbicide development experience, which have led to an evolving microbicide development algorithm, will be discussed. This article forms part of a special issue of Antiviral Research marking the 25th anniversary of anti-retroviral drug discovery and development, Vol 85, issue 1, 2010.

Segmented polyurethane intravaginal rings for the sustained combined delivery of antiretroviral agents dapivirine and tenofovir

Dual segment polyurethane intravaginal rings (IVRs) were fabricated to enable sustained release of antiretroviral agents dapivirine and tenofovir to prevent the male to female sexual transmission of the human immunodeficiency virus. Due to the contrasting hydrophilicity of the two drugs, dapivirine and tenofovir were separately formulated into polymers with matching hydrophilicity via solvent casting and hot melt extrusion. The resultant drug loaded rods were then joined together to form dual segment IVRs. Compression testing of the IVRs revealed that they are mechanically comparable to the widely accepted NuvaRing IVR. Physical characterization of the individual IVR segments using wide angle X-ray scattering and differential scanning calorimetry determined that dapivirine and tenofovir are amorphous and crystalline within their polymeric segments, respectively. In vitro release of tenofovir from the dual segment IVR was sustained over 30 days while dapivirine exhibited linear release over the time period. A 90 day accelerated stability study confirmed that dapivirine and tenofovir are stable in the IVR formulation. Altogether, these results suggest that multisegment polyurethane IVRs are an attractive formulation for the sustained vaginal delivery of drugs with contrasting hydrophilicity such as dapivirine and tenofovir.

Cycle control, tolerability, efficacy and acceptability of the vaginal contraceptive ring, NuvaRing®: Results of clinical experience in Germany

OBJECTIVES

To investigate the real-life clinical experience of NuvaRing users in Germany.

METHODS

An open-label, prospective, uncontrolled, non-randomized, multicentre postmarketing surveillance study was conducted by 1204 gynaecologists amongst 5823 women requesting contraception. The women underwent routine examinations and contraceptive counselling, and were assessed after three and six cycles of NuvaRing use.

RESULTS

Good cycle control was observed and there was a reduction in cycle irregularity and inter-menstrual bleeding, bleeding duration and intensity, and dysmenorrhoea. NuvaRing was well tolerated, and had no significant effect on body weight or blood pressure. Nine women became pregnant unintentionally (two had conceived before they started to use NuvaRing, three due to non-compliance, one because of repeated ring expulsion/loss and three during treatment in spite of having applied this latter as instructed). Most women expressed their satisfaction with NuvaRing; 82% were 'very satisfied/ satisfied', 72% planned to continue using it and 82% would recommend it to others. More than 90% of women found NuvaRing 'without problems/easy' to insert and to remove, and more than 80% of the women and their partners were not disturbed by its presence during intercourse.

CONCLUSION

NuvaRing is a highly effective and acceptable method of once-monthly contraception that is safe and well tolerated.

Clinical experience with NuvaRing® in daily practice in Switzerland: Cycle control and acceptability among women of all reproductive ages

OBJECTIVES

To assess clinical experience with NuvaRing in daily practice in Switzerland, including a large subgroup of young women (aged < or = 22 years).

METHODS

Open, prospective, multicentre, observational clinical experience study to investigate cycle control, acceptability and usage of NuvaRing.

RESULTS

Altogether, 2642 women participated in the programme and were included in the analysis, of which 658 were aged < or = 22 years (25% of the total group). A total of 744 women (28% of the total group) discontinued NuvaRing use; the main reason was adverse events (11% of all users). In younger women, there was a shift from moderate (-18%) and heavy (-45%) bleeding to mild bleeding (+71%) and dysmenorrhoea decreased by 60%, despite previous hormonal contraception use by 83% of women. Most women found ring insertion and removal to be straightforward (>95%), and were satisfied with its use (85%), primarily for the ring's once-a-month application (81%). Data were very similar for the total group. Cycle control and satisfaction were further improved with duration of treatment.

CONCLUSIONS

In daily practice, NuvaRing improved cycle control and was highly acceptable to women, including young women. Switchers from other hormonal methods also showed improved cycle control and high satisfaction.

The combined contraceptive vaginal device (NuvaRing®): A comprehensive review

OBJECTIVES

The aim of this study is to review the development of NuvaRing over the past decade to illustrate its use-effectiveness and acceptance as an alternative contraceptive option for women.

METHODS

The data were extracted from the literature using computerised MEDLINE system. NuvaRing is a new combined hormonal contraceptive vaginal ring made of ethylene-vinyl-acetate copolymer, releasing 120 microg etonorgestrel and 15 microg ethinyloestradiol per day. This ring is inserted on any day from day 1 to day 5 of a menstrual cycle for 21 days, thereafter removed for 7 days ring-free period and discarded.

RESULTS

Complete inhibition of ovulation is observed during treatment with this device. Clinical exposure to NuvaRing for 1786 women-years has resulted in 21 pregnancies, giving a Pearl Index of 1.18. Withdrawal bleeding (4.7-5.3 days) is regular (97-99% of cycles) with rare incidence of irregular bleeding (2.6-6.4%). The cycle control is good with the use of this combined contraceptive vaginal ring. NuvaRing is well tolerated and accepted by women as compared to oral pill.

CONCLUSIONS

NuvaRing is an effective vaginal contraceptive option for women. However, further study is needed for monitoring its long-term effectiveness and impact on patient's quality of life since the NuvaRing is marketed in many countries.