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Plagianos MG, Ramanadhan S, Merkatz RB, Brache V, Friedland BA, Haddad LB. Risk factors for and outcomes of ring expulsions with a 1-year contraceptive vaginal system. Am J Obstet Gynecol 2024; 230:548.e1-548.e8. [PMID: 38295968 DOI: 10.1016/j.ajog.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 01/03/2024] [Accepted: 01/19/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND The US Food and Drug Administration-approved segesterone acetate and ethinyl estradiol ring-shaped contraceptive vaginal system, known as Annovera (Sever Pharma Solutions/QPharma, Malmö, Sweden), was inserted and removed under a woman's control for a 21 day in and 7 day out regimen for up to 13 cycles of use. OBJECTIVE We aimed to describe the patterns of ring expulsion over time, to identify potential predictors of expulsion, and to evaluate the impact of expulsions on method discontinuation and pregnancy risk. STUDY DESIGN Using data from 2064 participants who were enrolled in 2 multinational phase 3 clinical trials on the use of this contraceptive vaginal system, we examined data from participants' daily diaries for documentation of complete ring expulsion. We modeled the odds of reported expulsions over time with adjustment for background and demographic characteristics using mixed-effects logistic regression models with random intercepts. We compared the probability of continuation between those who did and those who did not report expulsions in the first cycle of use using survival analysis and hazards modeling. To determine if expulsions during the first cycle of use affected the risk for pregnancy, we calculated Pearl Indices. RESULTS Most participants (75%) never experienced any expulsions during any cycle of use, and 91% to 97% did not experience an expulsion during any 1 cycle. The incidence of expulsion was highest in cycle 1 (9%). The odds of experiencing expulsions decreased by half in cycles 2 to 8 when compared with cycle 1 (0.48; 95% confidence interval, 0.40-0.58), and in cycles 9 to 13, expulsions were about a third of that in cycle 1 (0.32; 95% confidence interval, 0.26-0.41). Of those who did experience expulsions, most (62%-84%) experienced ≤2 expulsions per cycle. Participants from study sites in Latin America vs those in the United States had higher odds of not experiencing an expulsion (odds ratio, 1.95; 95% confidence interval, 1.45-2.63). Women with a higher education level had higher odds of experiencing an expulsion. Notably, parity, age, and body mass index were not associated with expulsion. Participants who experienced any expulsions in cycle 1 were more likely to discontinue use early (hazard ratio, 1.28; 95% confidence interval, 1.14-1.43) than participants who did not have an expulsion. The Pearl Index for participants who had expulsions during cycle 1 was 3.99 (95% confidence interval, 1.29-9.31), which was higher than that among participants who reported no expulsions (Pearl Index, 2.39; 95% confidence interval, 1.61-3.41), but the overlapping confidence intervals indicate that there is not sufficient evidence to demonstrate an association between expulsions and pregnancy risk. CONCLUSION Expulsions were infrequent overall, decreased with subsequent cycles of use, and were not associated with body mass index or parity. Early discontinuation of product use was higher among participants who experienced an expulsion during cycle 1. Although it is unclear whether pregnancy risk was associated with expulsions, early recognition of expulsions among users may identify those at higher risk for discontinuation and may highlight when enhanced anticipatory counselling and guidance may be advantageous.
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Shapley-Quinn MK, Song M, Chen BA, Devlin B, Luecke E, Brown J, Blithe DL, Achilles SL, van der Straten A. Participant experiences with a multipurpose vaginal ring for HIV and pregnancy prevention during a phase 1 clinical trial: learning from users to improve acceptability. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1147628. [PMID: 37484873 PMCID: PMC10359149 DOI: 10.3389/frph.2023.1147628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/01/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction With high concurrent global rates of HIV incidence and unintended pregnancy, there is a need to provide options beyond condoms to enable users to simultaneously prevent HIV acquisition and pregnancy. Multiple vaginal rings are in development as "MPTs" (multipurpose prevention technologies) as they are shown to provide several co-occurring benefits such as discretion, convenience, reversibility and user control. Methods In this Phase 1 trial of a 3-month MPT ring in the U.S., 25 participants (low-risk for HIV and pregnancy) were randomized to use the study ring for 90 days continuously or in 28-day cycles with 2-day removal periods in between. All participants completed in-depth interviews at the end of their study participation. Results Overall, the ring was well tolerated. Participants resoundingly endorsed the concept of an extended-use, dual-purpose vaginal ring, but reported too many functional challenges and side effects to endorse this particular ring. Participants assigned to the continuous regimen reported more positive experiences with ring use than those in the cyclic group. A minority of participants who experienced minimal side effects and did not experience challenges with vaginal retention of the ring found it appealing. However, the majority of participants experienced challenges (ring slippage, expulsions, side effects, vaginal bleeding changes) with product use that outweighed the potential benefits and led them to report that - in the future - they would not be interested in using this specific version of the ring in its current form. A subset expressed interest in using the current MPT ring under certain conditions (e.g., if fewer expulsions, less bleeding, higher risk for HIV/pregnancy). Discussion User feedback regarding participant experiences and challenges with the study ring was continuously shared with the product developer, underscoring the value of early-stage end-user feedback in product development.
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Affiliation(s)
| | - Mei Song
- Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Beatrice A. Chen
- Magee-Womens Research Institute, Pittsburgh, PA, United States
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Brid Devlin
- Center for Biomedical Research, Population Council, New York, NY, United States
| | - Ellen Luecke
- Women’s Global Health Imperative, RTI International, Berkeley, CA, United States
| | - Jill Brown
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Diana L. Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Sharon L. Achilles
- Magee-Womens Research Institute, Pittsburgh, PA, United States
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- ASTRA Consulting, Kensington, CA, United States
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Abdollahpour S, Ashrafizaveh A, Azmoude E. Effects of the Combined Contraceptive Vaginal Ring on Female Sexual Function: A Systematic Review and Meta-analysis. Malays J Med Sci 2023; 30:21-30. [PMID: 36875197 PMCID: PMC9984104 DOI: 10.21315/mjms2023.30.1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/29/2021] [Indexed: 03/05/2023] Open
Abstract
There are controversial debates regarding the effects of contraceptive vaginal ring devices on females' sexual function. Therefore, the meta-analysis of before-after was conducted on the intervention studies published in the past years to clarify these contradictions. The existing literature on the subject was reviewed by searching through such databases as PubMed, Scopus, ISI Web of Sciences, Embase, Cochrane Library and Google Scholar up to July 2021. Before-after intervention studies that had examined the effect of vaginal rings on females' sexual function were collected as well. In total, five studies with 369 participants were included in quantitative syntheses. Pooled results from the random-effect model showed that NuvaRing had a positive effect on females' sexual function three months after insertion (WMD: 2.48; 95% CI: 0.30, 4.67; P = 0.026); however, this effect was not significant after 6 months (WMD: 4.38; 95% CI: -4.95, 13.72; P = 0.357). Meta-regression analysis suggested that the effect of this device is associated with users' age and body mass index 3 months after insertion. No publication bias was found by Egger's test or funnel plots. Overall, the results of this meta-analysis support the view that vaginal ring use is associated with a positive effect on the sexual function of women 3 months after insertion, while the effect of this device on the sexual function of women was insignificant after 6 months. However, given the dearth of available data, it is not possible to reach a definite conclusion on the effect of vaginal rings on females' sexual function.
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Affiliation(s)
- Sedigheh Abdollahpour
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Akram Ashrafizaveh
- Department of Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Elham Azmoude
- Department of Midwifery, Neyshabur University of Medical Sciences, Neyshabur, Iran
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Tolley EE, Zissette S, Taylor J, Hanif H, Ju S, Schwarz J, Thurman A, Tyner D, Brache V, Doncel GF. Acceptability of a Long-Acting, Multipurpose Vaginal Ring: Findings from a Phase I Trial in the U.S. and Dominican Republic. J Womens Health (Larchmt) 2022; 31:1343-1352. [PMID: 35363574 PMCID: PMC9527051 DOI: 10.1089/jwh.2021.0394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Women worldwide face risks from pregnancy, HIV, and other sexually transmitted infections (STIs). To date, highly effective contraceptive methods provide no HIV/STI protection, and HIV prevention products, excluding condoms, provide no pregnancy protection. Intravaginal rings (IVRs) delivering antiretrovirals and contraceptives are a promising multipurpose prevention technology (MPT). Methods: Embedded within a Phase I randomized, placebo-controlled trial, we examined acceptability of continuous versus interrupted use of a 90-day MPT IVR among 47 low-risk women in Norfolk, Virginia and the Dominican Republic. A baseline survey assessed menstruation attitudes, risk perceptions and trial-related motivations. Follow-up surveys (M1/M3) examined user experiences with and preferences for IVR attributes; 18 women also participated in two in-depth interviews. Results: Most women rated the IVR's flexibility and smoothness (86%) and ease of insertion/removal (76%) as very acceptable. Fewer women similarly rated the IVR size (57%) and changes in color from menstruation (52%). Most participants experienced no changes or less bleeding. Those reporting more/heavier bleeding (20% M1, 15% M3) disliked the change. Overall, women preferred a 3-month (75%) to a 1-month IVR (7.5%) or a bimonthly injectable (10%). In qualitative interviews, women were willing to continuously use an IVR for 6–12 months, providing it did not “degrade” inside the body. Reasons for trial participation and prevention preferences, menstrual attitudes, and perceived IVR benefits and doubts varied by site. Conclusions: Findings provide strong evidence of demand for an MPT IVR that protects from pregnancy and HIV/STIs, lasts longer than 1 month, minimally disrupts menstrual bleeding, and is in women's control. numberClinicalTrials.gov: #NCT03279120.
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Affiliation(s)
- Elizabeth E Tolley
- Behavioral, Epidemiological & Clinical Sciences, FHI 360, Durham, North Carolina, USA
| | - Seth Zissette
- Rollins School of Public Health, Emory University, Department of Epidemiology (PhD Student), Atlanta, GA, USA
| | - Jamilah Taylor
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Homaira Hanif
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Susan Ju
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Jill Schwarz
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Andrea Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Arany P, Papp I, Zichar M, Regdon G, Béres M, Szalóki M, Kovács R, Fehér P, Ujhelyi Z, Vecsernyés M, Bácskay I. Manufacturing and Examination of Vaginal Drug Delivery System by FDM 3D Printing. Pharmaceutics 2021; 13:1714. [PMID: 34684007 PMCID: PMC8539995 DOI: 10.3390/pharmaceutics13101714] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
Vaginal drug delivery systems can provide a long-term and constant liberation of the active pharmaceutical ingredient even for months. For our experiment, FDM 3D printing was used to manufacture the vaginal ring samples from thermoplastic polyurethane filament, which enables fast manufacturing of complex, personalized medications. 3D printing can be an excellent alternative instead of industrial manufacturing, which is complicated and time-consuming. In our work, the 3D printed vaginal rings were filled manually with jellified metronidazole or chloramphenicol for the treatment of bacterial vaginosis. The need for manual filling was certified by the thermogravimetric and heatflow assay results. The manufactured samples were analyzed by an Erweka USP type II Dissolution Apparatus, and the dissolution profile can be distinguished based on the applied jellifying agents and the API's. All samples were considered non-similar based on the pairwise comparison. The biocompatibility properties were determined by prolonged MTT assay on HeLa cells, and the polymer could be considered non-toxic. Based on the microbiological assay on E. coli metronidazole and chitosan containing samples had bactericidal effects while just metronidazole or just chitosan containing samples bacteriostatic effect. None of these samples showed a fungistatic or fungicide effect against C. albicans. Based on our results, we successfully manufactured 3D printed vaginal rings filled with jellified metronidazole.
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Affiliation(s)
- Petra Arany
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei Körút 98, H-4032 Debrecen, Hungary; (P.A.); (P.F.); (Z.U.); (M.V.)
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, Nagyerdei Körút 98, H-4032 Debrecen, Hungary
| | - Ildikó Papp
- Department of Computer Graphics and Image Processing, Faculty of Informatics, University of Debrecen, Kassai út 26, H-4028 Debrecen, Hungary; (I.P.); (M.Z.)
| | - Marianna Zichar
- Department of Computer Graphics and Image Processing, Faculty of Informatics, University of Debrecen, Kassai út 26, H-4028 Debrecen, Hungary; (I.P.); (M.Z.)
| | - Géza Regdon
- Institute of Pharmaceutical Technology and Regulatory Affairs, University of Szeged, Eötvös u. 6, H-6720 Szeged, Hungary;
| | - Mónika Béres
- Department of Medical Imaging, Faculty of Medicine, University of Debrecen, Nagyerdei Krt. 98, H-4032 Debrecen, Hungary;
| | - Melinda Szalóki
- Department of Biomaterials and Prosthetic Dentistry, Faculty of Dentistry, University of Debrecen, Nagyerdei Körút 98, H-4032 Debrecen, Hungary;
| | - Renátó Kovács
- Department of Medical Microbiology, Faculty of Medicine and Pharmacy, University of Debrecen, Nagyerdei Körút 98, H-4032 Debrecen, Hungary;
| | - Pálma Fehér
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei Körút 98, H-4032 Debrecen, Hungary; (P.A.); (P.F.); (Z.U.); (M.V.)
| | - Zoltán Ujhelyi
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei Körút 98, H-4032 Debrecen, Hungary; (P.A.); (P.F.); (Z.U.); (M.V.)
| | - Miklós Vecsernyés
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei Körút 98, H-4032 Debrecen, Hungary; (P.A.); (P.F.); (Z.U.); (M.V.)
| | - Ildikó Bácskay
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei Körút 98, H-4032 Debrecen, Hungary; (P.A.); (P.F.); (Z.U.); (M.V.)
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Johnston DS, Goldberg E. Preclinical contraceptive development for men and women. Biol Reprod 2021; 103:147-156. [PMID: 32561907 DOI: 10.1093/biolre/ioaa076] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 12/16/2022] Open
Abstract
This manuscript endeavors to present research considerations for the preclinical development of non-hormonal contraceptives. Topics include (1) how advances in genomics and bioinformatics impact the identification of novel targets for non-hormonal contraception, (2) the importance of target validation prior to investment in a contraceptive development campaign, (3) considerations on targeting gametogenesis vs gamete maturation/function, (4) how targets from the male reproductive system are expanding women's options for 'on demand' contraception, and (5) some emerging non-hormonal methods that are not based on a specific molecular target. Also presented are ideas for developing a pipeline of non-hypothalamic-pituitary-gonadal-acting contraceptives for men and women while balancing risk and innovation, and our perspective on the pros and cons of industry and academic environments on contraceptive development. Three product development programs are highlighted that are biologically interesting, innovative, and likely to influence the field of contraceptive development in years to come.
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Affiliation(s)
- Daniel S Johnston
- Contraception Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Erwin Goldberg
- Department of Molecular Biosciences, Northwestern University, Evanston, IL, USA
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das Neves J, Notario-Pérez F, Sarmento B. Women-specific routes of administration for drugs: A critical overview. Adv Drug Deliv Rev 2021; 176:113865. [PMID: 34280514 DOI: 10.1016/j.addr.2021.113865] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 12/19/2022]
Abstract
The woman's body presents a number of unique anatomical features that can constitute valuable routes for the administration of drugs, either for local or systemic action. These are associated with genitalia (vaginal, endocervical, intrauterine, intrafallopian and intraovarian routes), changes occurring during pregnancy (extra-amniotic, intra-amniotic and intraplacental routes) and the female breast (breast intraductal route). While the vaginal administration of drug products is common, other routes have limited clinical application and are fairly unknown even for scientists involved in drug delivery science. Understanding the possibilities and limitations of women-specific routes is of key importance for the development of new preventative, diagnostic and therapeutic strategies that will ultimately contribute to the advancement of women's health. This article provides an overview on women-specific routes for the administration of drugs, focusing on aspects such as biological features pertaining to drug delivery, relevance in current clinical practice, available drug dosage forms/delivery systems and administration techniques, as well as recent trends in the field.
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Rafiei F, Tabesh H, Farzad S, Farzaneh F, Rezaei M, Hosseinzade F, Mottaghy K. Development of Hormonal Intravaginal Rings: Technology and Challenges. Geburtshilfe Frauenheilkd 2021; 81:789-806. [PMID: 34276064 PMCID: PMC8277443 DOI: 10.1055/a-1369-9395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/20/2021] [Indexed: 12/24/2022] Open
Abstract
Intravaginal rings (IVRs) are minimally invasive polymeric devices specifically designed to be used for the sustained and prolonged release of various type of drugs such as hormones. One of the benefits of using topical drug delivery systems (e.g., IVRs) is the fact that systemic drug delivery may cause drug resistance due to elevated drug levels. Topical drug delivery also provides higher concentrations of the drug to the target site and has fewer side effects. In addition, when a drug is administered vaginally, the hepatic first-pass effect is avoided, resulting in higher absorption. Contraception and treatments for specific diseases such as endometriosis and hormone deficiencies can be improved by the administration of hormones via an IVR. This article aims to classify and compare various designs of commercially available and non-commercial hormonal IVRs and to analyze their performance. Current challenges affecting the development of IVRs are investigated, and
proposed solutions are discussed. A comprehensive search of publications in MEDLINE/PubMed and of commercial product data of IVRs was performed, and the materials, designs, performance, and applications (e.g., contraception, endometriosis, estrogen deficiency and urogenital atrophy) of hormonal IVRs were thoroughly evaluated. Most hormonal IVRs administer female sex hormones, i.e., estrogen and progestogens. In terms of material, IVRs are divided into 3 main groups: silicone, polyurethane, and polyethylene-co-vinyl acetate IVRs. As regards their design, there are 4 major designs for IVRs which strongly affect their performance and the timing and rate of hormone release. Important challenges include reducing the burst release and maintaining the bioavailability of hormones at their site of action over a prolonged period of administration as well as lowering production costs. Hormonal IVRs are a promising method which could be used to facilitate combination therapies by
administering multiple drugs in a single IVR while eliminating the side effects of conventional drug administration methods. IVRs could considerably improve womenʼs quality of life all over the world within a short period of time.
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Affiliation(s)
- Fojan Rafiei
- Department of Life Science Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
| | - Hadi Tabesh
- Department of Life Science Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
| | - Shayan Farzad
- Department of Biomedical Engineering, University of Southern California, Los Angeles, California, United States
| | - Farah Farzaneh
- Preventative Gynecology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Rezaei
- Department of Life Science Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
| | - Fateme Hosseinzade
- Department of Life Science Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
| | - Khosrow Mottaghy
- Institute of Physiology, RWTH Aachen University, Aachen, Germany
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Carson L, Merkatz R, Martinelli E, Boyd P, Variano B, Sallent T, Malcolm RK. The Vaginal Microbiota, Bacterial Biofilms and Polymeric Drug-Releasing Vaginal Rings. Pharmaceutics 2021; 13:pharmaceutics13050751. [PMID: 34069590 PMCID: PMC8161251 DOI: 10.3390/pharmaceutics13050751] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/26/2022] Open
Abstract
The diversity and dynamics of the microbial species populating the human vagina are increasingly understood to play a pivotal role in vaginal health. However, our knowledge about the potential interactions between the vaginal microbiota and vaginally administered drug delivery systems is still rather limited. Several drug-releasing vaginal ring products are currently marketed for hormonal contraception and estrogen replacement therapy, and many others are in preclinical and clinical development for these and other clinical indications. As with all implantable polymeric devices, drug-releasing vaginal rings are subject to surface bacterial adherence and biofilm formation, mostly associated with endogenous microorganisms present in the vagina. Despite more than 50 years since the vaginal ring concept was first described, there has been only limited study and reporting around bacterial adherence and biofilm formation on rings. With increasing interest in the vaginal microbiome and vaginal ring technology, this timely review article provides an overview of: (i) the vaginal microbiota, (ii) biofilm formation in the human vagina and its potential role in vaginal dysbiosis, (iii) mechanistic aspects of biofilm formation on polymeric surfaces, (iv) polymeric materials used in the manufacture of vaginal rings, (v) surface morphology characteristics of rings, (vi) biomass accumulation and biofilm formation on vaginal rings, and (vii) regulatory considerations.
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Affiliation(s)
- Louise Carson
- School of Pharmacy, Queen’s University Belfast, Belfast BT9 7BL, UK; (L.C.); (P.B.)
| | - Ruth Merkatz
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Elena Martinelli
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Peter Boyd
- School of Pharmacy, Queen’s University Belfast, Belfast BT9 7BL, UK; (L.C.); (P.B.)
| | - Bruce Variano
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Teresa Sallent
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Robert Karl Malcolm
- School of Pharmacy, Queen’s University Belfast, Belfast BT9 7BL, UK; (L.C.); (P.B.)
- Correspondence:
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Hughes SM, Pandey U, Johnston C, Marrazzo J, Hladik F, Micks E. Impact of the menstrual cycle and ethinyl estradiol/etonogestrel contraceptive vaginal ring on granulysin and other mucosal immune mediators. Am J Reprod Immunol 2021; 86:e13412. [PMID: 33641250 DOI: 10.1111/aji.13412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/13/2022] Open
Abstract
PROBLEM Changes in sex hormones during the menstrual cycle and contraceptive vaginal ring (CVR) use influence immunity within the female genital tract, but the magnitude of these effects and their anatomical location are unclear. METHOD OF STUDY In a prospective study, 29 women were assessed at three-time points: follicular phase, luteal phase, and one month after initiation of the ethinyl estradiol/etonogestrel CVR (NuvaRing®, Merck). We performed microarrays on endocervical cytobrushes and measured immune mediators in cervicovaginal fluid, adjusting for bacterial vaginosis and the presence of blood. We compared these results to public gene expression data from the fallopian tubes, endometrium, endo- and ectocervix, and vagina. RESULTS Immune-related gene expression in the endocervix and immune mediators in cervicovaginal fluid increased during CVR use versus both menstrual phases, and in the follicular versus luteal phase. The antimicrobial protein granulysin was high during CVR use, intermediate in the follicular phase, and nearly absent from the luteal phase. Re-analysis of public gene expression data confirmed increased immune-related gene expression in the endocervix during the follicular phase. However, in the fallopian tube, endometrium, and vagina, the follicular phase showed immunosuppression. CONCLUSIONS Immune-related genes in the cervicovaginal tract were highest during CVR use, intermediate in the follicular phase, and lowest in the luteal phase. Granulysin is a potential biomarker of menstrual phase: Frequently detected in follicular samples, but rare in luteal. Lastly, immunological differences between the follicular and luteal phases vary throughout the female genital tract.
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Affiliation(s)
- Sean M Hughes
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Urvashi Pandey
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Christine Johnston
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Jeanne Marrazzo
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Florian Hladik
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Elizabeth Micks
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
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de Jesus Antunes N, de Oliveira Filho RV, de Oliveira Ilha J, Moreno RA, Nahoum AF, Wedemeyer RS, Warnke A, De Nucci G. Single-dose pharmacokinetics and pharmacodynamics assessment of oestriol and trimegestone containing vaginal rings in healthy women with childbearing potential. EUR J CONTRACEP REPR 2021; 26:184-194. [PMID: 33645377 DOI: 10.1080/13625187.2021.1884219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE To evaluate the pharmacokinetics and pharmacodynamics of oestriol (E3) and trimegestone (TMG) in healthy women after application of three different vaginal rings over 21 days. The vaginal rings had a nominal delivery rate of 0.413/0.050 mg/day (Test 1), 0.311/0.090 mg/day (Test 2) and 0.209/0.137 mg/day (Test 3) E3/TMG. METHODS Thirty-five healthy women were randomised to receive a single application of Test 1, 2 or 3 (Clinical Trial NCT03343912). The E3 and TMG plasma concentration was determined by LC-MS/MS. Oestradiol (E2) and progesterone (PG) serum concentrations, and bleeding patern were determined as pharmacodynamic parameters. Safety was assessed by evaluation of adverse events and local tolerability. RESULTS The total and maximum exposure of E3 and TMG increased in a proportional ratio to dose. However, not in a magnitude which was expected from the dose differences for E3. During Test 2 and 3 treatment all E2 and PG values remained on a well suppressed level until end of treatment. E2 and PG serum levels increased distinctly earlier after ring removal with Test 1 compared to Test 2 and 3. Test 3 achieved 95.24% of "no bleeding" days under treatment followed by Test 1 (91.67%), and Test 2 (86.15%). CONCLUSIONS The Test 3 formulation presented the best dose combination of E3/TMG for contraception. Moreover, all vaginal rings were well tolerated.
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Affiliation(s)
- Natalícia de Jesus Antunes
- Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | | | | | - Ronilson A Moreno
- Department of Food Science, School of Food Engineering, UNICAMP, Campinas, Brazil
| | - André Felipe Nahoum
- Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | | | | | - Gilberto De Nucci
- Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil.,Institute of Biomedical Sciences, University of São Paulo (USP), São Paulo, Brazil.,Faculty of Medicine, São Leopoldo Mandic (SLMANDIC), Campinas, Brazil
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12
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Abstract
While contraceptive drugs have enabled many people to decide when they want to have a baby, more than 100 million unintended pregnancies each year in the world may indicate the contraceptive requirement of many people has not been well addressed yet. The vagina is a well-established and practical route for the delivery of various pharmacological molecules, including contraceptives. This review aims to present an overview of different contraceptive methods focusing on the vaginal route of delivery for contraceptives, including current developments, discussing the potentials and limitations of the modern methods, designs, and how well each method performs for delivering the contraceptives and preventing pregnancy.
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13
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Boyd P, Merkatz R, Variano B, Malcolm RK. The ins and outs of drug-releasing vaginal rings: a literature review of expulsions and removals. Expert Opin Drug Deliv 2020; 17:1519-1540. [DOI: 10.1080/17425247.2020.1798927] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Peter Boyd
- School of Pharmacy, Queen’s University Belfast, Belfast, UK
| | - Ruth Merkatz
- Population Council, One Dag Hammarskjold Plaza, New York, NY, USA
| | - Bruce Variano
- Population Council, One Dag Hammarskjold Plaza, New York, NY, USA
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14
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Controlled-Release from High-Loaded Reservoir-Type Systems-A Case Study of Ethylene-Vinyl Acetate and Progesterone. Pharmaceutics 2020; 12:pharmaceutics12020103. [PMID: 32013050 PMCID: PMC7076478 DOI: 10.3390/pharmaceutics12020103] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/14/2020] [Accepted: 01/26/2020] [Indexed: 12/13/2022] Open
Abstract
Reservoir systems (drug-loaded core surrounded by drug-free membrane) provide long-term controlled drug release. This is especially beneficial for drug delivery to specific body regions including the vagina. In this study, we investigated the potential of reservoir systems to provide high drug release rates over several weeks. The considered model system was an intra-vaginal ring (IVR) delivering progesterone (P4) in the mg/day range using ethylene-vinyl acetate (EVA) as release rate-controlling polymers. To circumvent the high material needs associated with IVR manufacturing, we implemented a small-scale screening procedure that predicts the drug release from IVRs. Formulations were designed based on the solubility and diffusivity of P4 in EVAs with varying vinyl acetate content. High in-vitro P4 release was achieved by i) high P4 solubility in the core polymer; ii) high P4 partition coefficient between the membrane and the core; and/or iii) low membrane thicknesses. It was challenging for systems designed to release comparatively high fractions of P4 at early times to retain a constant drug release over a long time. P4 crystal dissolution in the core could not counterbalance drug diffusion through the membrane and drug crystal dissolution was found to be the rate-limiting step. Overall, high P4 release rates can be achieved from EVA-based reservoir systems.
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15
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Grandi G, Timò A, Sammarini M, Del Savio MC, Facchinetti F. Surface roughness of different contraceptive vaginal rings: evaluation by scanning electron microscope (SEM). EUR J CONTRACEP REPR 2020; 25:60-64. [PMID: 31922428 DOI: 10.1080/13625187.2019.1709964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Objective: The aim of the study was to evaluate whether the compositions of the ethylene vinyl acetate (EVA) membrane of two different contraceptive vaginal rings could influence the surface roughness, which is associated with the possible accumulation of vaginal biomass on the rings during use.Methods: We measured and compared the surface roughness of unused vaginal rings, NuvaRing and Ornibel, using a scanning electron microscope (SEM) and dedicated software that can convert SEM images into 3D models. Average roughness (Ra), average quadratic roughness (Rq) and mean height of the irregularities at 10 points (Rz) were calculated.Results: Different thicknesses of the EVA membranes between the two rings were noted. No significant differences were found between the two rings in the three evaluated values of surface roughness (NuvaRing vs Ornibel, respectively: Ra, 1.53 ± 0.14 vs 1.61 ± 0.14 µm, p = 0.141; Rq, 2.03 ± 0.25 vs 2.07 ± 0.16 µm, p = 0.688; Rz, 11.4 ± 3.1 vs 11.4 ± 2.4 µm, p = 0.987).Conclusion: The different composition of the vaginal rings' EVA membrane is not associated with different surface roughness. Ornibel is equivalent to NuvaRing in terms of surface roughness, despite the different composition of the membrane polymers.
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Affiliation(s)
- Giovanni Grandi
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Alex Timò
- Department for Quality and Regulatory Affairs, JDentalCare srl, Modena, Italy
| | - Margaret Sammarini
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Chiara Del Savio
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Facchinetti
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
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16
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Undie CC, RamaRao S, Mbow FB. Choosing and Using the Progesterone Vaginal Ring: Women's Lived Experiences in Three African Cities. Patient Prefer Adherence 2020; 14:1761-1770. [PMID: 33061318 PMCID: PMC7532896 DOI: 10.2147/ppa.s265503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/08/2020] [Indexed: 12/05/2022] Open
Abstract
PURPOSE This study explored experiences of selecting and utilizing a newly introduced contraceptive - the progesterone vaginal ring (PVR) - among women seeking a contraceptive method in 3 African capital cities (Abuja, Nairobi, and Senegal). The study explored women's perceptions of, and lived experiences with, using the new product to better understand their reception of a new contraceptive. This understanding will help inform the design of programs to support women in their adoption and continued use of the PVR and other new contraceptives. PATIENTS AND METHODS This longitudinal, qualitative study drew on an interpretive phenomenological approach, involving multiple in-depth interviews (IDIs) with 9 study participants over a 6-month period. Participants involved in the study were postpartum women seeking contraceptive services at participating clinics. A total of 25 IDIs were conducted, and a detailed "within-case" and "cross-case" analysis of participants' accounts was carried out to identify similar and dissimilar themes along descriptive, linguistic, and conceptual lines. RESULTS Four overarching themes emerged from the analysis. These themes circulated around the unconventionality of the PVR, which heightened its desirability among participants; the sense of comfort that women gained from opting to use the PVR over other FP methods; narratives of consideration that centered on women's partners, and that were important for ensuring the sustainability of women's PVR use; and the conundrums that women grappled with as they prepared to disengage from the PVR after two cycles of use. CONCLUSION The PVR is an acceptable contraceptive method to postpartum women in urban African settings. However, prior to its introduction into new country contexts, formative data on women's perceptions of, and reactions to, the product need to inform country preparation processes. Such information would be useful for tailoring counseling around this contraceptive, as well as for product marketing and robust uptake of the method.
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Affiliation(s)
- Chi-Chi Undie
- Reproductive Health Program, Population Council, Nairobi, Kenya
- Correspondence: Chi-Chi Undie Email
| | - Saumya RamaRao
- Reproductive Health Program, Population Council, New York, NY, USA
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17
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Hormonal Contraception and Female Sexuality: Position Statements from the European Society of Sexual Medicine (ESSM). J Sex Med 2019; 16:1681-1695. [DOI: 10.1016/j.jsxm.2019.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/31/2019] [Accepted: 08/02/2019] [Indexed: 12/17/2022]
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18
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Tietz K, Klein S. In Vitro Methods for Evaluating Drug Release of Vaginal Ring Formulations-A Critical Review. Pharmaceutics 2019; 11:pharmaceutics11100538. [PMID: 31623277 PMCID: PMC6836189 DOI: 10.3390/pharmaceutics11100538] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/09/2019] [Accepted: 10/14/2019] [Indexed: 12/28/2022] Open
Abstract
The vagina is a promising site for both local and systemic drug delivery and represents an interesting administration route for compounds with poor oral bioavailability. Whereas most of the currently marketed dosage forms were designed as immediate release formulations, intravaginal rings (IVRs) offer the possibility of a controlled vaginal drug delivery over several weeks or months. For a long time, the development of IVRs was limited to steroid-releasing formulations. Recently, IVRs have witnessed a surge of new interest as promising delivery systems for microbicides. Therefore, various novel IVR designs have been introduced. To ensure that only safe and effective IVRs will be administered to patients, it is important to properly distinguish between IVRs with desired and undesired release performance. In vitro methods for evaluating drug release of IVRs that present with sufficient predictive capacity for in vivo drug release, and discriminatory power with regard to IVRs quality, are an essential tool for this purpose. The objective of the present review article is to present the current status of in vitro drug release testing of IVRs and to critically discuss current compendial and non-official in vitro drug release methods with regard to their discriminatory power and in vivo predictivity.
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Affiliation(s)
- Katharina Tietz
- Center of Drug Absorption and Transport, Institute of Biopharmaceutics and Pharmaceutical Technology, Department of Pharmacy, Felix-Hausdorff-Str. 3, University of Greifswald, Greifswald 17489, Germany
| | - Sandra Klein
- Center of Drug Absorption and Transport, Institute of Biopharmaceutics and Pharmaceutical Technology, Department of Pharmacy, Felix-Hausdorff-Str. 3, University of Greifswald, Greifswald 17489, Germany.
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19
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In vitro release testing methods for drug-releasing vaginal rings. J Control Release 2019; 313:54-69. [PMID: 31626862 DOI: 10.1016/j.jconrel.2019.10.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/05/2019] [Accepted: 10/08/2019] [Indexed: 12/28/2022]
Abstract
Drug-releasing vaginal rings are torus-shaped devices, generally fabricated from thermoplastic polymers or silicone elastomers, used to administer pharmaceutical drugs to the human vagina for periods typically ranging from three weeks to twelve months. One of the most important product performance tests for vaginal rings is the in vitro release test. Although it has been fifty years since a vaginal ring device was first described in the scientific literature, and despite seven drug-releasing vaginal rings having been approved for market, there is no universally accepted method for testing in vitro drug release, and only one non-compendial shaking incubator method (for the estradiol-releasing ring Estring®) is described in the US Food and Drug Administration's Dissolution Methods Database. Here, for the first time, we critically review the diverse range of test methods that have been described in the scientific literature for testing in vitro release of drug-releasing vaginal rings. Issues around in vitro-in vivo correlation and modelling of in vitro release data are also discussed.
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20
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Vargas SE, Midoun MM, Guillen M, Getz ML, Underhill K, Kuo C, Guthrie KM. A Qualitative Systematic Review of Women's Experiences Using Contraceptive Vaginal Rings: Implications for New Technologies. INTERNATIONAL PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2019; 45:25-34. [PMID: 31592770 DOI: 10.1363/45e7619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
CONTEXT Vaginal rings are available for contraception and hormone replacement, and are being developed as HIV/STD or multipurpose prevention technologies. A comprehensive understanding of women's expectations of and experiences with rings is urgently needed to inform product development and to optimize ring use. METHODS Three databases (PubMed, Global Health and CINAHL) were searched for English-language, peer-reviewed articles published between January 1996 and November 2017 that reported qualitative data on barriers to and facilitators of use of female-controlled contraceptive methods. Data on study methods, findings and conclusions pertaining to contraceptive rings were extracted, organized and analyzed. RESULTS Twenty-six articles, all published since 2008, met the inclusion criteria. Seven studies focused largely or entirely on rings (and involved current, former or potential users), while the others focused on other contraceptive methods but included ring-specific data. Familiarity with the ring was low, and women commonly had initial concerns about the method-often related to insertion and removal, cleanliness and discomfort with touching their vagina-that were typically overcome over time. Other major themes were issues related to ring use and discontinuation, the importance of ring-related properties and characteristics, and considerations related to sexual partners and health care providers. CONCLUSIONS Qualitative data have the potential to inform ring design and promotion. Future research should further explore women's expectations and experiences with the ring, the value of involving male partners in ring evaluation, and evaluation of interventions to improve patient-provider communication concerning ring choice and use.
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Affiliation(s)
- Sara E Vargas
- Research scientist, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI,
| | - Miriam M Midoun
- Graduate student, Department of Comparative Human Development, University of Chicago
| | - Melissa Guillen
- Project director, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | | | - Kristen Underhill
- Associate professor, Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York
| | - Caroline Kuo
- Associate professor (research), Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI
| | - Kate M Guthrie
- Senior research scientist, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
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21
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Caruso S, Panella M, Giunta G, Matarazzo MG, Cianci A. Comparative randomized study on the sexual function and quality of life of women on contraceptive vaginal ring containing ethinylestradiol/etonogestrel 3.47/11.00mg or 2.7/11.7mg. Gynecol Endocrinol 2019; 35:899-903. [PMID: 30990099 DOI: 10.1080/09513590.2019.1603290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
The objective of the study was to evaluate the sexual function and quality of life (QoL) of healthy women on a new contraceptive vaginal ring (CVR) containing ethinylestradiol (EE) 3.47 mg and etonogestrel (ENG) 11.00 mg (study group) manufactured with a new polymer composition compared to EE 2.7 mg/ENG11.7 mg CVR (control group). Fifty-eight women were randomly allocated to the study group and the control group. The Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS) and the Short Form-36, were used to assess sexual function, sexual distress and QoL, respectively. The study included two follow-ups, at 90 days and at 180 days. The control group reported more adverse events, mainly breakthrough bleeding, than the study group. The sexual function scores in the women in the study group improved with respect to those of the control group both at the 1st (FSFI, p = .009; FSDS, p = .001) and at the 2nd (FSFI, p = .001; FSDS, p = .002) follow-up. QoL of the study group improved at the 1st follow-up (p < .05) and 2nd (p < .01) follow-up. The control group improved their QoL at the 2nd follow-up (p < .01). The more gradual EE release of the new polymer composition could justify the behavioral differences of the women of the two groups.
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Affiliation(s)
- Salvatore Caruso
- Departemt of General Surgery and Medical Surgical Specialties, University of Catania-Italy Research Group for Sexology, Catania, Italy
| | - Marco Panella
- Departemt of General Surgery and Medical Surgical Specialties, University of Catania-Italy Research Group for Sexology, Catania, Italy
| | - Giuliana Giunta
- Departemt of General Surgery and Medical Surgical Specialties, University of Catania-Italy Research Group for Sexology, Catania, Italy
| | - Maria Grazia Matarazzo
- Departemt of General Surgery and Medical Surgical Specialties, University of Catania-Italy Research Group for Sexology, Catania, Italy
| | - Antonio Cianci
- Departemt of General Surgery and Medical Surgical Specialties, University of Catania-Italy Research Group for Sexology, Catania, Italy
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22
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Efficacy of the 1-year (13-cycle) segesterone acetate and ethinylestradiol contraceptive vaginal system: results of two multicentre, open-label, single-arm, phase 3 trials. LANCET GLOBAL HEALTH 2019; 7:e1054-e1064. [PMID: 31231065 PMCID: PMC6624423 DOI: 10.1016/s2214-109x(19)30265-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 04/19/2019] [Accepted: 05/07/2019] [Indexed: 11/22/2022]
Abstract
Background A ring-shaped, contraceptive vaginal system designed to last 1 year (13 cycles) delivers an average of 0·15 mg segesterone acetate and 0·013 mg ethinylestradiol per day. We evaluated the efficacy of this contraceptive vaginal system and return to menses or pregnancy after use. Methods In two identically designed, multicentre, open-label, single-arm, phase 3 trials (one at 15 US academic and community sites and one at 12 US and international academic and community sites), participants followed a 21-days-in, 7-days-out segesterone acetate and ethinylestradiol contraceptive vaginal system schedule for up to 13 cycles. Participants were healthy, sexually active, non-pregnant, non-sterilised women aged 18–40 years. Women were cautioned that any removals during the 21 days of cyclic use should not exceed 2 h, and used daily paper diaries to record vaginal system use. Consistent with regulatory requirements for contraceptives, we calculated the Pearl Index for women aged 35 years and younger, excluding adjunctive contraception cycles, as the primary efficacy outcome measure. We also did intention-to-treat Kaplan-Meier life table analyses and followed up women who did not use hormonal contraceptives or desired pregnancy after study completion for 6 months for return to menses or pregnancy. The trials are registered with ClinicalTrials.gov, numbers NCT00455156 and NCT00263341. Findings Between Dec 19, 2006, and Oct 9, 2009, at the 15 US sites, and between Nov 1, 2006, and July 2, 2009, at the 12 US and international sites we enrolled 2278 women. Our overall efficacy analysis included 2265 participants (1130 in the US study and 1135 in the international study) and 1303 (57·5%) participants completed up to 13 cycles. The Pearl Index for the primary efficacy group was 2·98 (95% CI 2·13–4·06) per 100 woman-years, and was well within the range indicative of efficacy for a contraceptive under a woman's control. The Kaplan-Meier analysis revealed the contraceptive vaginal system was 97·5% effective, which provided further evidence of efficacy. Pregnancy occurrence was similar across cycles. All 290 follow-up participants reported return to menses or became pregnant (24 [63%] of 38 women who desired pregnancy) within 6 months. Interpretation The segesterone acetate and ethinylestradiol contraceptive vaginal system is an effective contraceptive for 13 consecutive cycles of use. This new product adds to the contraceptive method mix and the 1-year duration of use means that women do not need to return to the clinic or pharmacy for refills every few months. Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health, the US Agency for International Development, and the WHO Reproductive Health Research Department.
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23
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Temmerman M. A new woman-controlled contraceptive vaginal ring: a global step forward. LANCET GLOBAL HEALTH 2019; 7:e986-e987. [PMID: 31231064 DOI: 10.1016/s2214-109x(19)30289-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Marleen Temmerman
- Aga Khan University, Nairobi 00100, Kenya; Ghent University, Ghent, Belgium.
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24
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Vargas SE, Midoun MM, Guillen M, Getz ML, Underhill K, Kuo C, Guthrie KM. A Qualitative Systematic Review of Women's Experiences Using Contraceptive Vaginal Rings: Implications for New Technologies. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2019; 51:71-80. [PMID: 31108027 PMCID: PMC6662569 DOI: 10.1363/psrh.12103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/28/2019] [Accepted: 03/26/2019] [Indexed: 06/09/2023]
Abstract
CONTEXT Vaginal rings are available for contraception and hormone replacement, and are being developed as HIV/STD or multipurpose prevention technologies. A comprehensive understanding of women's expectations of and experiences with rings is urgently needed to inform product development and to optimize ring use. METHODS Three databases (PubMed, Global Health and CINAHL) were searched for English-language, peer-reviewed articles published between January 1996 and November 2017 that reported qualitative data on barriers to and facilitators of use of female-controlled contraceptive methods. Data on study methods, findings and conclusions pertaining to contraceptive rings were extracted, organized and analyzed. RESULTS Twenty-six articles, all published since 2008, met the inclusion criteria. Seven studies focused largely or entirely on rings (and involved current, former or potential users), while the others focused on other contraceptive methods but included ring-specific data. Familiarity with the ring was low, and women commonly had initial concerns about the method-often related to insertion and removal, cleanliness and discomfort with touching their vagina-that were typically overcome over time. Other major themes were issues related to ring use and discontinuation, the importance of ring-related properties and characteristics, and considerations related to sexual partners and health care providers. CONCLUSIONS Qualitative data have the potential to inform ring design and promotion. Future research should further explore women's expectations and experiences with the ring, the value of involving male partners in ring evaluation, and evaluation of interventions to improve patient-provider communication concerning ring choice and use.
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Affiliation(s)
- Sara E. Vargas
- Research scientist, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | - Miriam M. Midoun
- Graduate student, Department of Comparative Human Development, University of Chicago
| | - Melissa Guillen
- Project director, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | | | - Kristen Underhill
- Associate professor, Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York
| | - Caroline Kuo
- Associate professor (research), Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence
| | - Kate M. Guthrie
- Senior research, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
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25
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Koutsamanis I, Eder S, Beretta M, Witschnigg A, Paudel A, Nickisch K, Friedrich M, Eggenreich K, Roblegg E. Formulation and processability screening for the rational design of ethylene-vinyl acetate based intra-vaginal rings. Int J Pharm 2019; 564:90-97. [DOI: 10.1016/j.ijpharm.2019.04.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/12/2019] [Accepted: 04/13/2019] [Indexed: 10/27/2022]
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26
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McLellan-Lemal E, Gvetadze R, Desai MA, Makanga EM, Pan Y, Haaland RE, Holder AN, Mudhune V, Williams T, Samandari T. Non-adherence among women enrolled in a contraceptive vaginal ring use study in Kisumu, Kenya, 2014-2015. JOURNAL OF GLOBAL HEALTH REPORTS 2018; 2. [PMID: 30976663 DOI: 10.29392/joghr.2.e2018032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Given future potential use of vaginal rings to prevent HIV infection, we examined the association of contraceptive vaginal ring (CVR) non-adherence with user dissatisfaction, tolerability, demographic, and behavioral factors. Methods In an open-label single-group study, sexually active women aged 18-34 years using oral or injectable hormonal contraception, conveniently sampled from general population, were assigned to 6-month use of a commercial CVR currently not licensed for use in Kenya. Non-adherence in any CVR cycle completed was assessed from: (1) self-report (not used for at least 1 day), and (2) pharmacy record (failure to timely receive a new CVR or return a used one). Additionally, non-adherence was assessed in a subset of participants by residual progestin and estrogen levels measured in returned CVRs. Results Of 202 participants who underwent CVR insertion by a study clinician, 142 completed all 6 visits, 172 responded to questions about ring use, and 43 provided used CVRs from months 1, 3, and 6 for residual hormone analysis. Non-adherence was 14.0% (24/172) by self-report and 54.5% (110/202) by pharmacy record. Non-adherence by pharmacy record was significantly reduced among women with a salary-based income (prevalence ratio (PR) 0.71, 95% confidence interval (CI) (0.55-0.91)] compared to women with income not salary-based or no income. Participants dissatisfied with CVR on ≥4 aspects (ambiguity of instructions, inconvenience of use, sensation, sexual discomfort, etc.) were more likely to report non-adherence (PR 2.69, 95% CI=(1.31-5.52)] compared to those dissatisfied with ≤3 aspects. Non-adherence by residual hormone levels was identified in 46.5% (20/43) participants. Over time, this subset of participants showed increasing non-adherence (P=0.004). We found lack of agreement among the various measures of non-adherence. Conclusions Economic empowerment interventions, especially those emphasizing partner-independent income options, and expanded education on CVR features may alleviate non-adherence. Addressing CVR dissatisfaction preemptively may also help mitigate non-adherence.
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Affiliation(s)
- Eleanor McLellan-Lemal
- Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
| | - Roman Gvetadze
- Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
| | - Mitesh A Desai
- Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
| | - Esther M Makanga
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Yi Pan
- Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
| | - Richard E Haaland
- Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
| | - Angela N Holder
- Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
| | - Victor Mudhune
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Tiffany Williams
- Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA.,ICF, Atlanta, Georgia, USA
| | - Taraz Samandari
- Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
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Monteiro I, Guazzelli CF, Bahamondes L. Advances in contraceptive vaginal rings: what does the future hold? Expert Opin Pharmacother 2018; 19:1685-1691. [PMID: 30286682 DOI: 10.1080/14656566.2018.1519549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Contraceptive vaginal rings (CVRs) are good contraceptive options because they do not require skilled providers, are self-administered, and show a higher stability of drug diffusion. AREAS COVERED This article provides a review of the developments made with CVRs over the past number of years, while giving focus to the latest CVRs that have gone through clinical development. The author of the article also provides an expert perspective on the future of these useful therapeutic options. EXPERT OPINION Pharmacokinetic studies have shown that segesterone, an absorbable progestin that is used alone or in combination with ethinyl estradiol (EE) or E2, is the CVR of choice at this present time. Indeed, segesterone has demonstrated safety and efficacy as a CVR and is also an appropriate option for lactating women, as they are not absorbed orally. However, good cycle control is important for improved CVR adherence. CVRs that allow the combination of more than one drug may unravel another multi-purpose use when combined with microbicides and could provide combined protection to women who wish to protect themselves from pregnancy and sexually transmitted infection.
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Affiliation(s)
- Ilza Monteiro
- a Family Planning clinic, Department of Obstetrics and Gynecology , Federal University of Medical School , São Paulo, Campinas , Brazil
| | - Cristina Falbo Guazzelli
- b Family Planning clinic, Department of Obstetrics and Gynecology , University of Campinas Medical School , São Paulo , Brazil
| | - Luis Bahamondes
- a Family Planning clinic, Department of Obstetrics and Gynecology , Federal University of Medical School , São Paulo, Campinas , Brazil
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Wang Y, Boyd P, Hunter A, Malcolm RK. Intravaginal rings for continuous low-dose administration of cervical ripening agents. Int J Pharm 2018; 549:124-132. [DOI: 10.1016/j.ijpharm.2018.07.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/28/2018] [Accepted: 07/22/2018] [Indexed: 12/31/2022]
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Kestelyn E, Van Nuil JI, Umulisa MM, Umutoni G, Uwingabire A, Mwambarangwe L, Uwineza M, Agaba S, Crucitti T, van de Wijgert J, Delvaux T. High acceptability of a contraceptive vaginal ring among women in Kigali, Rwanda. PLoS One 2018; 13:e0199096. [PMID: 29912906 PMCID: PMC6005526 DOI: 10.1371/journal.pone.0199096] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 05/31/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Introduction of contraceptive vaginal rings (CVRs) could expand the contraceptive method mix reducing the unmet need for family planning in Rwanda, but data on acceptability of CVRs from low and middle-income countries are lacking. METHODS This study explores acceptability of contraceptive vaginal ring (NuvaRing) use in Kigali, Rwanda using a mixed methods approach. We collected quantitative and qualitative data before, during and after conducting a clinical trial, using Case Report Forms, Interviewer Administered Questionnaires, In Depth Interviews and Focus Group Discussions. We analyzed the data using an existing theoretical framework including product attributes, relationship attributes and sexual encounter attributes as well as the contextual environment. RESULTS Our data showed that initial worries reduced over time with actual ring use and ring insertions and removals were described as easy. Most women did not feel the ring during daily activities, appreciated the lack of perceived negative side effects and the increased lubrication. Relationship attributes and sexual encounter attributes such as sexual comfort played a significant role in ring acceptability of the participants and their partners. The contextual environment including Rwandan cultural norms around sexuality positively influenced the acceptance of the NuvaRing. Overall satisfaction was high. CONCLUSIONS Acceptability of the Nuvaring was high among study participants and represents a promising option that could contribute to lowering the unmet need for family planning in Rwanda.
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Affiliation(s)
- Evelyne Kestelyn
- Rinda Ubuzima, Kigali, Rwanda
- University of Liverpool, Institute of Infection and Global Health, Liverpool, United kingdom
| | - Jennifer Ilo Van Nuil
- Rinda Ubuzima, Kigali, Rwanda
- University of Liverpool, Institute of Infection and Global Health, Liverpool, United kingdom
| | | | | | | | | | | | | | | | - Janneke van de Wijgert
- University of Liverpool, Institute of Infection and Global Health, Liverpool, United kingdom
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Abstract
Over the last century, there has been a dramatic change in the nature of therapeutic, biologically active molecules available to treat disease. Therapies have evolved from extracted natural products towards rationally designed biomolecules, including small molecules, engineered proteins and nucleic acids. The use of potent drugs which target specific organs, cells or biochemical pathways, necessitates new tools which can enable controlled delivery and dosing of these therapeutics to their biological targets. Here, we review the miniaturisation of drug delivery systems from the macro to nano-scale, focussing on controlled dosing and controlled targeting as two key parameters in drug delivery device design. We describe how the miniaturisation of these devices enables the move from repeated, systemic dosing, to on-demand, targeted delivery of therapeutic drugs and highlight areas of focus for the future.
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Affiliation(s)
- Derfogail Delcassian
- a David H. Koch Institute for Integrative Cancer Research , Massachusetts Institute of Technology , Cambridge , MA , USA.,b Department of Anaesthesiology , Boston Children's Hospital, Harvard Medical School , Boston , MA , USA.,c Division of Regenerative Medicine and Cellular Therapies, School of Pharmacy , University of Nottingham , Nottingham , UK
| | - Asha K Patel
- a David H. Koch Institute for Integrative Cancer Research , Massachusetts Institute of Technology , Cambridge , MA , USA.,d Division of Cancer and Stem Cells, School of Medicine, and Division of Advanced Materials and Healthcare Technologies, School of Pharmacy , University of Nottingham , Nottingham , UK
| | - Abel B Cortinas
- a David H. Koch Institute for Integrative Cancer Research , Massachusetts Institute of Technology , Cambridge , MA , USA.,e Department of Chemical Engineering , Massachusetts Institute of Technology , Cambridge , MA , USA
| | - Robert Langer
- a David H. Koch Institute for Integrative Cancer Research , Massachusetts Institute of Technology , Cambridge , MA , USA.,e Department of Chemical Engineering , Massachusetts Institute of Technology , Cambridge , MA , USA.,f Institute for Medical Engineering and Science , Massachusetts Institute of Technology , Cambridge , MA , USA.,g Media Lab , Massachusetts Institute of Technology , Cambridge , MA , USA
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Algorta J, Diaz M, de Benito R, Lefebvre M, Sicard E, Furtado M, Regidor PA, Ronchi C. Pharmacokinetic bioequivalence, safety and acceptability of Ornibel ®, a new polymer composition contraceptive vaginal ring (etonogestrel/ethinylestradiol 11.00/3.474 mg) compared with Nuvaring ® (etonogestrel/ethinylestradiol 11.7/2.7 mg). EUR J CONTRACEP REPR 2018; 22:429-438. [PMID: 29336615 DOI: 10.1080/13625187.2017.1413179] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To show the clinical development of Ornibel® (ExeltisHealthcare, Spain) a contraceptive vaginal ring manufactured with a new polymer composition and containing etonogestrel/ethinylestradiol, compared to Nuvaring® (MSD, Spain). SUBJECTS AND METHODS Randomised, single dose, 2-period, 2-sequence, 2-stage crossover, comparative bioavailability study conducted in 40 healthy female subjects. All subjects received both treatments for 28 days in each of two periods, separated by a 28 days washout. Ornibel® contains etonogestrel/ethinylestradiol 11.00/3.47 mg and Nuvaring® contains etonogestrel/ethinylestradiol 11.7/2.7 mg, both rings delivering 120/15 µg/day. For the calculation of pharmacokinetic parameters, 37 blood samples were collected up to 840 h after each ring insertion to quantify plasma concentrations of etonogestrel and ethinylestradiol using a validated MS/MS-HPLC. Safety was assessed by adverse events recording, clinical laboratory and vital signs and tolerability by vaginal examination. Acceptability was investigated by a 5-point scale questionnaire. RESULTS Bioequivalence was demonstrated in the first stage as the 94.12% Confidence Intervals of the primary parameters laid within the 80-125% acceptance range for both etonogestrel (Cmax: 96.81-112.20%; AUC0-504h: 98.71-108.61%; AUC0-t: 100.14-109.10%) and ethinylestradiol. (Cmax: 105.91-120.62%; AUC0-504h: 105.47-114.59%; AUC0-t: 108.31-117.61%). During the first day of use a burst effect was observed with Nuvaring®, with significantly higher level of ethinylestradiol (Cmax0-24h ratio: 78.34%, 94.12CI: 73.55-83.45%). Both products were well tolerated and accepted, without significant differences between them. CONCLUSION Ornibel® is bioequivalent to Nuvaring® in terms of efficacy, safety, tolerability and acceptability. The new polymer composition provides Ornibel® with more stability and gradual hormonal release during the first day of use, particularly for ethinylestradiol.
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Affiliation(s)
- Jaime Algorta
- a Medical Department , Chemo Group , Azuqueca , Spain
| | - Maria Diaz
- a Medical Department , Chemo Group , Azuqueca , Spain
| | | | - Marc Lefebvre
- b Scientific Department , Altasciences (Algorithme Pharma Inc) , Laval , Quebec , Canada
| | - Eric Sicard
- c Clinical Department , Altasciences (Algorithme Pharma Inc) , Laval , Quebec , Canada
| | - Milton Furtado
- d Bioanalytical Department , Altasciences (Algorithme Pharma Inc) , Laval , Quebec , Canada
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Polymeric gels for intravaginal drug delivery. J Control Release 2018; 270:145-157. [DOI: 10.1016/j.jconrel.2017.12.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/30/2017] [Accepted: 12/05/2017] [Indexed: 12/14/2022]
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Jug M, Hafner A, Lovrić J, Kregar ML, Pepić I, Vanić Ž, Cetina-Čižmek B, Filipović-Grčić J. An overview of in vitro dissolution/release methods for novel mucosal drug delivery systems. J Pharm Biomed Anal 2018; 147:350-366. [DOI: 10.1016/j.jpba.2017.06.072] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/19/2017] [Accepted: 06/19/2017] [Indexed: 01/12/2023]
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Patel RC, Bukusi EA, Baeten JM. Current and future contraceptive options for women living with HIV. Expert Opin Pharmacother 2017; 19:1-12. [PMID: 28891343 DOI: 10.1080/14656566.2017.1378345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Among women living with HIV, half of the pregnancies are unintended. Effective contraception can prevent unintended pregnancies and consequently reduce maternal mortality and perinatal transmission of HIV. While contraceptive options available for all women also apply to women living with HIV, specific considerations exist to the use of contraception by women living with HIV. AREAS COVERED First, general principles guiding the use of contraception among women living with HIV are discussed, such as choice, method mix, relative effectiveness, and drug-drug interactions. Second, a detailed discussion of each contraceptive method and issues surrounding the use of that method, such as drug-drug interactions, follows. Third, future contraceptive options in advanced development for use by women or men are briefly discussed. EXPERT OPINION Contraceptive methods available to all women should also be accessible to women living with HIV. When the relative effectiveness of a contraceptive method is reduced, for example due to drug-drug interactions with antiretrovirals, the method should still be made available to women living with HIV with the appropriate information sharing and counseling. Greater research on various aspects of contraceptive use by women living with HIV and more comprehensive testing of co-administration of hormonal contraceptives and common medications used by these women are warranted.
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Affiliation(s)
- Rena C Patel
- a Division of Allergy and Infectious Diseases, Department of Medicine , University of Washington , Seattle , WA , USA
| | - Elizabeth A Bukusi
- b Centre for Microbiologic Research , Kenya Medical Research Institute ; Nairobi , Kenya.,c Departments of Obstetrics and Gynecology and Global Health , University of Washington ; Seattle , WA , USA
| | - Jared M Baeten
- d Departments of Epidemiology, Global Health, and Medicine , University of Washington ; Seattle , WA , USA
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McKay PF, Mann JFS, Pattani A, Kett V, Aldon Y, King D, Malcolm RK, Shattock RJ. Intravaginal immunisation using a novel antigen-releasing ring device elicits robust vaccine antigen-specific systemic and mucosal humoral immune responses. J Control Release 2017; 249:74-83. [PMID: 28115243 PMCID: PMC5333785 DOI: 10.1016/j.jconrel.2017.01.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 12/23/2016] [Accepted: 01/10/2017] [Indexed: 01/28/2023]
Abstract
The generation of effective levels of antigen-specific immunity at the mucosal sites of pathogen entry is a key goal for vaccinologists. We explored topical vaginal application as an approach to initiate local antigen-specific immunity, enhance previously existing systemic immunity or re-target responses to the mucosae. To deliver a protein vaccine formulation to the vaginal mucosal surface, we used a novel vaginal ring device comprising a silicone elastomer body into which three freeze-dried, rod-shaped, hydroxypropylmethylcellulose inserts were incorporated. Each rod contained recombinant HIV-1 CN54gp140 protein (167μg)±R848 (167μg) adjuvant. The inserts were loaded into cavities within each ring such that only the ends of the inserts were initially exposed. Sheep received a prime-boost vaccination regime comprising intramuscular injection of 100μg CN54gp140+200μg R848 followed by three successive ring applications of one week duration and separated by one month intervals. Other sheep received only the ring devices without intramuscular priming. Serum and vaginal mucosal fluids were sampled every two weeks and analysed by CN54gp140 ELISA and antigen-specific B cells were measured by flow cytometry at necropsy. Vaccine antigen-specific serum antibody responses were detected in both the intramuscularly-primed and vaginal mucosally-primed groups. Those animals that received only vaginal vaccinations had identical IgG but superior IgA responses. Analysis revealed that all animals exhibited mucosal antigen-specific IgG and IgA with the IgA responses 30-fold greater than systemic levels. Importantly, very high numbers of antigen-specific B cells were detected in local genital draining lymph nodes. We have elicited local genital antigen-specific immune responses after topical application of an adjuvanted antigen formulation within a novel vaginal ring vaccine release device. This regimen and delivery method elicited high levels of antigen-specific mucosal IgA and large numbers of local antigen-reactive B cells, both likely essential for effective mucosal protection.
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Affiliation(s)
- Paul F McKay
- Imperial College London, Department of Medicine, Division of Infectious Diseases, Section of Virology, Norfolk Place, London W2 1PG, UK.
| | - Jamie F S Mann
- Imperial College London, Department of Medicine, Division of Infectious Diseases, Section of Virology, Norfolk Place, London W2 1PG, UK
| | - Aditya Pattani
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Vicky Kett
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Yoann Aldon
- Imperial College London, Department of Medicine, Division of Infectious Diseases, Section of Virology, Norfolk Place, London W2 1PG, UK
| | - Deborah King
- Imperial College London, Department of Medicine, Division of Infectious Diseases, Section of Virology, Norfolk Place, London W2 1PG, UK
| | - R Karl Malcolm
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Robin J Shattock
- Imperial College London, Department of Medicine, Division of Infectious Diseases, Section of Virology, Norfolk Place, London W2 1PG, UK
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Filipović M, Đekić L. Characteristics of vaginal delivery systems. ARHIV ZA FARMACIJU 2017. [DOI: 10.5937/arhfarm1706360f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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van der Straten A, Panther L, Laborde N, Hoesley CJ, Cheng H, Husnik MJ, Horn S, Nel A, Soto-Torres L, Chen BA. Adherence and Acceptability of a Multidrug Vaginal Ring for HIV Prevention in a Phase I Study in the United States. AIDS Behav 2016; 20:2644-2653. [PMID: 26837628 PMCID: PMC4970965 DOI: 10.1007/s10461-016-1299-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We evaluated the adherence and acceptability of a vaginal ring containing dapivirine, maraviroc, or both drugs for 28 days during a Phase I placebo-controlled trial in 48 HIV-negative sexually abstinent U.S. women aged 18-40. Adherence was assessed weekly by clinical interview and computer-assisted self-interviewing; acceptability assessment occurred at the last product-use visit. Study retention was 98 % (47/48); 94 % (45/48) reported being fully adherent with ring use during the 28-day period. Two participants experienced the ring partially coming out. Analysis was blinded and behavioral data were combined across study groups. Most women reported being very comfortable having the ring in their vagina; 44 % preferred continuous use, whereas 51 % had no preference compared to episodic use. Although a range of minor ring concerns were expressed, few were actually experienced. High adherence to and acceptability of this vaginal ring in this Phase I trial contributes to its promise as a sustained mechanism for multidrug vaginal microbicide delivery.
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Affiliation(s)
- Ariane van der Straten
- Women's Global Health Imperative (WGHI), RTI International, 351 California St., Suite, 500, San Francisco, CA, 94104, USA.
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA.
| | | | - Nicole Laborde
- Women's Global Health Imperative (WGHI), RTI International, 351 California St., Suite, 500, San Francisco, CA, 94104, USA
| | | | - Helen Cheng
- Women's Global Health Imperative (WGHI), RTI International, 351 California St., Suite, 500, San Francisco, CA, 94104, USA
| | - Marla J Husnik
- Statistical Center for HIV/AIDS Research & Prevention/Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Annalene Nel
- International Partnership for Microbicides (IPM), Silver Spring, MD, USA
| | | | - Beatrice A Chen
- Magee-Womens Research Institute and University of Pittsburgh, Pittsburgh, PA, USA
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das Neves J, Martins JP, Sarmento B. Will dapivirine redeem the promises of anti-HIV microbicides? Overview of product design and clinical testing. Adv Drug Deliv Rev 2016; 103:20-32. [PMID: 26732684 DOI: 10.1016/j.addr.2015.12.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 12/17/2015] [Accepted: 12/17/2015] [Indexed: 12/19/2022]
Abstract
Microbicides are being developed in order to prevent sexual transmission of HIV. Dapivirine, a non-nucleoside reverse transcriptase inhibitor, is one of the leading drug candidates in the field, currently being tested in various dosage forms, namely vaginal rings, gels, and films. In particular, a ring allowing sustained drug release for 1month is in an advanced stage of clinical testing. Two parallel phase III clinical trials are underway in sub-Saharan Africa and results are expected to be released in early 2016. This article overviews the development of dapivirine and its multiple products as potential microbicides, with particular emphasis being placed on clinical evaluation. Also, critical aspects regarding regulatory approval, manufacturing, distribution, and access are discussed.
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Affiliation(s)
- José das Neves
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal; INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal; CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde & Instituto Universitário de Ciências da Saúde, Gandra, Portugal.
| | - João Pedro Martins
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal; INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal
| | - Bruno Sarmento
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal; INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal; CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde & Instituto Universitário de Ciências da Saúde, Gandra, Portugal
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Grandi G, Napolitano A, Cagnacci A. Metabolic impact of combined hormonal contraceptives containing estradiol. Expert Opin Drug Metab Toxicol 2016; 12:779-87. [DOI: 10.1080/17425255.2016.1190832] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Giovanni Grandi
- Department of Obstetrics Gynecology and Pediatrics, Obstetrics and Gynecology Unit, Azienda Ospedaliero Universitaria Policlinico of Modena, Modena, Italy
| | - Antonella Napolitano
- Department of Obstetrics Gynecology and Pediatrics, Obstetrics and Gynecology Unit, Azienda Ospedaliero Universitaria Policlinico of Modena, Modena, Italy
| | - Angelo Cagnacci
- Department of Obstetrics Gynecology and Pediatrics, Obstetrics and Gynecology Unit, Azienda Ospedaliero Universitaria Policlinico of Modena, Modena, Italy
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Helbling IM, Ibarra JCD, Luna JA. The Use of Cellulose Membrane to Eliminate Burst Release from Intravaginal Rings. AAPS JOURNAL 2016; 18:960-71. [PMID: 27097635 DOI: 10.1208/s12248-016-9914-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/06/2016] [Indexed: 11/30/2022]
Abstract
Burst release was observed when ethylene vinyl acetate copolymer (EVA) intravaginal rings were tested for progesterone release in our previous work (Helbling et al. Pharm Res. 31(3):795-808, 2014). Burst release is undesirable in controlled delivery devices because release is uncontrollable and higher levels of active pharmaceutical ingredient could lead to the occurrence of adverse effect. The present contribution is about the use of membranes to coat EVA rings to eliminate burst release. Physicochemical state of progesterone in uncoated rings and the solubility and diffusion coefficient in membrane were studied. Hormone delivery from several rings of different sizes was compared. A mathematical model was used to analyze the effects of membrane properties on delivery rate. No chemical interactions were detected between hormone and polymer. Hormone was mainly forming amorphous aggregates inside rings, and migration to membrane was not observed during storage. Diffusion coefficient was smaller in membrane (∼10(-8) cm(2) s(-1)) than in matrix (∼10(-7) cm(2) s(-1)). Zero-order release kinetics were obtained for coated rings, and release rate decreases as the thickness of the coat increases. Cellulose membrane successfully eliminates burst release and controls the delivery from EVA rings. The equations developed can be used to determine the appropriate coat thickness to produce specific release rate.
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Affiliation(s)
- Ignacio M Helbling
- Laboratorio de Química Fina, Instituto de Desarrollo Tecnológico para la Industria Química (INTEC), Universidad Nacional del Litoral and Consejo Nacional de Investigaciones Científicas y Técnicas (UNL-CONICET), CCT CONICET-SANTA FE, Ruta Nacional 168, Paraje El Pozo, 3000, Santa Fe, Argentina.
| | - Juan C D Ibarra
- Laboratorio de Química Fina, Instituto de Desarrollo Tecnológico para la Industria Química (INTEC), Universidad Nacional del Litoral and Consejo Nacional de Investigaciones Científicas y Técnicas (UNL-CONICET), CCT CONICET-SANTA FE, Ruta Nacional 168, Paraje El Pozo, 3000, Santa Fe, Argentina
| | - Julio A Luna
- Laboratorio de Química Fina, Instituto de Desarrollo Tecnológico para la Industria Química (INTEC), Universidad Nacional del Litoral and Consejo Nacional de Investigaciones Científicas y Técnicas (UNL-CONICET), CCT CONICET-SANTA FE, Ruta Nacional 168, Paraje El Pozo, 3000, Santa Fe, Argentina
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Nanda K, Callahan R, Dorflinger L. Addressing gaps in the contraceptive method mix: methods in development. ACTA ACUST UNITED AC 2015; 11:729-35. [PMID: 26674125 DOI: 10.2217/whe.15.84] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite the availability of a variety of contraceptive methods, millions of women still have an unmet need for contraceptive choices. Short-acting methods are plagued by issues with adherence, leading to imperfect or inconsistent use and subsequent unintended pregnancy. Long-acting contraceptive methods such as intrauterine devices and contraceptive implants, while providing highly effective and safe contraception, do not meet the needs of all women, often due to cost, access or acceptability issues. Several new methods are in various stages of development and are designed to address the shortcomings of current methods. Providers should be aware of these future options and how they might better meet women's needs.
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Affiliation(s)
- Kavita Nanda
- Contraceptive Technology Innovation Department, Global Health, Population & Nutrition, FHI 360, Durham, NC, USA
| | - Rebecca Callahan
- Contraceptive Technology Innovation Department, Global Health, Population & Nutrition, FHI 360, Durham, NC, USA
| | - Laneta Dorflinger
- Contraceptive Technology Innovation Department, Global Health, Population & Nutrition, FHI 360, Durham, NC, USA
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Woodsong C, Holt JDS. Acceptability and preferences for vaginal dosage forms intended for prevention of HIV or HIV and pregnancy. Adv Drug Deliv Rev 2015; 92:146-54. [PMID: 25703190 DOI: 10.1016/j.addr.2015.02.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 01/22/2015] [Accepted: 02/06/2015] [Indexed: 11/28/2022]
Abstract
This paper reviews key issues found to affect acceptability and preferences for vaginal products to prevent HIV infection or HIV and pregnancy. We focus on the interplay between the biological and physico-chemical aspects of formulation and the social and behavioral issues that may affect use. The need for an HIV prevention product that women can use is driven by women's increased biological and social vulnerability to HIV infection, and thus social and behavioral research on microbicide acceptability has been conducted alongside, as well as separate from, the earliest product development efforts. Some acceptability and preference issues are specific to a product's dosage form, use-requirements, and/or use indications, while others pertain to any vaginal product used for prevention of HIV or pregnancy. Although most of the work cited here was published since 2010, it draws on a much longer trajectory of research.
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MESH Headings
- Administration, Intravaginal
- Anti-HIV Agents/administration & dosage
- Anti-HIV Agents/adverse effects
- Anti-HIV Agents/pharmacokinetics
- Contraceptive Agents, Female/administration & dosage
- Contraceptive Agents, Female/adverse effects
- Contraceptive Agents, Female/pharmacokinetics
- Drug Delivery Systems/methods
- Female
- HIV Infections/prevention & control
- Humans
- Patient Preference
- Pregnancy
- Pregnancy, Unplanned
- Vagina/physiology
- Vaginal Absorption
- Vaginal Creams, Foams, and Jellies/administration & dosage
- Vaginal Creams, Foams, and Jellies/adverse effects
- Vaginal Creams, Foams, and Jellies/pharmacokinetics
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Affiliation(s)
- Cynthia Woodsong
- International Partnership for Microbicides, 8401 Colesville Rd., Ste 200, Silver Spring MD 20910, USA.
| | - Jonathon D S Holt
- International Partnership for Microbicides, 8401 Colesville Rd., Ste 200, Silver Spring MD 20910, USA
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Huang Y, Merkatz RB, Hillier SL, Roberts K, Blithe DL, Sitruk-Ware R, Creinin MD. Effects of a One Year Reusable Contraceptive Vaginal Ring on Vaginal Microflora and the Risk of Vaginal Infection: An Open-Label Prospective Evaluation. PLoS One 2015; 10:e0134460. [PMID: 26267119 PMCID: PMC4534458 DOI: 10.1371/journal.pone.0134460] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 07/07/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A contraceptive vaginal ring (CVR) containing Nestorone® (NES) and ethinyl estradiol (EE) that is reusable for 1- year (13 cycles) is under development. This study assessed effects of this investigational CVR on the incidence of vaginal infections and change in vaginal microflora. METHODS There were 120 women enrolled into a NES/EE CVR Phase III trial and a microbiology sub-study for up to 1- year of cyclic product use. Gynecological examinations were conducted at baseline, the first week of cycle 6 and last week of cycle 13 (or during early discontinuation visits). Vaginal swabs were obtained for wet mount microscopy, Gram stain and culture. The CVR was removed from the vagina at the last study visit and cultured. Semi-quantitative cultures for Lactobacillus, Gardnerella vaginalis, Enterococcus faecalis, Staphylococcus aureus, Escherichia coli, anaerobic gram negative rods (GNRs), Candida albicans and other yeasts were performed on vaginal and CVR samples. Vaginal infections were documented throughout the study. RESULTS Over 1- year of use, 3.3% of subjects were clinically diagnosed with bacterial vaginosis, 15.0% with vulvovaginal candidiasis, and 0.8% with trichomoniasis. The detection rate of these three infections did not change significantly from baseline to either Cycle 6 or 13. Nugent scores remained stable. H2O2-positive Lactobacillus dominated vaginal flora with a non-significant prevalence increase from 76.7% at baseline to 82.7% at cycle 6 and 90.2% at cycle 13, and a median concentration of 107 colony forming units (cfu) per gram. Although anaerobic GNRs prevalence increased significantly, the median concentration decreased slightly (104 to 103cfu per gram). There were no significant changes in frequency or concentrations of other pathogens. High levels of agreement between vaginal and ring surface microbiota were observed. CONCLUSION Sustained use of the NES/EE CVR did not increase the risk of vaginal infection and was not disruptive to the vaginal ecosystem. TRIAL REGISTRATION ClinicalTrials.gov NCT00263341, NCT00455156.
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Affiliation(s)
- Yongmei Huang
- Population Council, Center for Biomedical Research, New York, United States of America
| | - Ruth B. Merkatz
- Population Council, Center for Biomedical Research, New York, United States of America
- * E-mail:
| | - Sharon L. Hillier
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh and the Magee-Womens Research Institute, Pittsburgh, United States of America
| | - Kevin Roberts
- Population Council, Center for Biomedical Research, New York, United States of America
| | - Diana L. Blithe
- Contraceptive Discovery and Development Branch, National Institute of Child Health and Human Development, Bethesda, United States of America
| | - Régine Sitruk-Ware
- Population Council, Center for Biomedical Research, New York, United States of America
| | - Mitchell D. Creinin
- Department of Obstetrics and Gynecology, University of California Davis, Sacramento, United States of America
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Halpern V, Stalter RM, Owen DH, Dorflinger LJ, Lendvay A, Rademacher KH. Towards the development of a longer-acting injectable contraceptive: past research and current trends. Contraception 2015; 92:3-9. [DOI: 10.1016/j.contraception.2015.02.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/10/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
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Toral MI, Nacaratte F, Nova F. Determination of Etonogestrel and Ethinyl Estradiol from an Intrauterine Contraceptive Ring by Extraction and Derivative Spectrophotometry. ANAL LETT 2015. [DOI: 10.1080/00032719.2014.968930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Woodsong C, Holt J, Devlin B, Rosenberg Z. Current Status of Multipurpose Prevention Technology (MPT) Development. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-014-0107-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Nguyen BT, Jensen JT. Evaluating the efficacy and safety of a progestin- and estrogen-releasing ethylene vinyl acetate copolymer contraceptive vaginal ring. Expert Opin Drug Saf 2014; 13:1423-30. [PMID: 25106828 DOI: 10.1517/14740338.2014.948842] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Multiple studies confirm the safety and efficacy of the combined ethinyl estradiol (EE) and etonogestrel contraceptive vaginal ring (NuvaRing®). Advantages of continuous drug delivery through the vagina compared to oral administration include stable levels of contraceptive steroids without the need for daily drug administration. Although the combined contraceptive vaginal ring (CCVR) avoids the problem of missed pills, clinical data do not support greater efficacy. Vaginal administration avoids first-pass hepatic effects; however, EE is a potent inducer of hepatic globulins regardless of the route of administration. Consequently, thromboembolic risk during CCVR use is similar to that with combined oral contraceptives. Some epidemiologic and database studies suggest that the risk of thromboembolism is increased among users of the CCVR compared to levonorgestrel-containing combined pills. AREAS COVERED This review examined the available literature for level 1 and level 2 evidence of the CCVR and its associated efficacy and safety. Studies are presented in table format with significant findings and conclusions described. EXPERT OPINION A prospective study with 33,235 woman-years of exposure and with greater ability to control for covariates did not demonstrate an elevation of risk. The safety profile of the CCVR appears to be the same as with other combined hormonal contraceptives.
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Affiliation(s)
- Brian Trung Nguyen
- Oregon Health and Science University, Department of Obstetrics and Gynecology , UHN-70, OHSU, 3181 SW Sam Jackson Park Road, Portland, OR 97239 , USA
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Abstract
Menstrual suppression to provide relief of menstrual-related symptoms or to manage medical conditions associated with menstrual morbidity or menstrual exacerbation has been used clinically since the development of steroid hormonal therapies. Options range from the extended or continuous use of combined hormonal oral contraceptives, to the use of combined hormonal patches and rings, progestins given in a variety of formulations from intramuscular injection to oral therapies to intrauterine devices, and other agents such as gonadotropin-releasing hormone (GnRH) antagonists. The agents used for menstrual suppression have variable rates of success in inducing amenorrhea, but typically have increasing rates of amenorrhea over time. Therapy may be limited by side effects, most commonly irregular, unscheduled bleeding. These therapies can benefit women’s quality of life, and by stabilizing the hormonal milieu, potentially improve the course of underlying medical conditions such as diabetes or a seizure disorder. This review addresses situations in which menstrual suppression may be of benefit, and lists options which have been successful in inducing medical amenorrhea.
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Affiliation(s)
- Paula Adams Hillard
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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