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Prifti C, Casas RS, Merriam S, Yecies E, Walsh JME. Update on Therapies and Treatments in Women's Health. Med Clin North Am 2024; 108:871-880. [PMID: 39084838 DOI: 10.1016/j.mcna.2024.03.007] [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] [Indexed: 08/02/2024]
Abstract
This article contains noninclusive language such as "females" and "women" when those terms were used in the research and historic context we are summarizing. New therapies have become available for vasomotor symptoms, postpartum depression, contraception, osteoporosis, recurrent yeast infections, acute and recurrent urinary tract infections, and female hypoactive sexual desire disorder. These therapies meet unique patient needs and change clinical practice for select groups. As is typical for new treatments, insurance coverage and access issues limit the adoption of some therapies.
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Affiliation(s)
- Christine Prifti
- Department of General Internal Medicine, Chobanian and Avedisian School of Medicine, Boston University Medical Center, 801 Massachusetts Avenue, 5th Floor, Suite 5A, Boston, MA 02118, USA.
| | - Rachel S Casas
- Department of Medicine, Division of General Internal Medicine, Penn State Milton S. Hershey Medical Center, Academic Support Building, 90 Hope Drive, Suite 3200, Mail Code A320, Hershey, PA 17033, USA. https://twitter.com/RachelCasas14
| | - Sarah Merriam
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, VA Pittsburgh Healthcare System, VA Hospital HJ Heinz, Primary Care, Building 71, 1010 Delafield Road, Pittsburgh, PA 15215, USA. https://twitter.com/SarahMerriamMD
| | - Emmanuelle Yecies
- Department of Primary Care and Population Health, Stanford University School of Medicine (affiliated), VA Palo Alto Healthcare System, 3801 Miranda Avenue, Building 5, Palo Alto, CA 94304, USA
| | - Judith M E Walsh
- School of Medicine, University of California, San Francisco, UCSF Valley Tower, 490 Illinois 8th Floor, Box 0856, San Francisco, CA 94158, USA
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Achilles SL, Kelly CW, Hoesley CJ, Blithe DL, Brown J, Richardson BA, Devlin B, Hendrix CW, Poloyac SM, Marzinke MA, Gundacker H, Singh D, Piper JM, Johnson S, Steytler J, Chen BA. Phase 1 randomized trials to assess safety, pharmacokinetics, and vaginal bleeding associated with use of extended duration dapivirine and levonorgestrel vaginal rings. PLoS One 2024; 19:e0304552. [PMID: 38838028 PMCID: PMC11152307 DOI: 10.1371/journal.pone.0304552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 05/14/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Vaginal rings formulated to deliver two drugs simultaneously have potential as user-controlled, long-acting methods for dual prevention of HIV and pregnancy. METHODS Two phase 1 randomized trials (MTN-030/IPM 041 and MTN-044/IPM 053/CCN019) respectively enrolled 24 and 25 healthy, HIV-negative participants to evaluate safety, pharmacokinetics, and vaginal bleeding associated with use of a vaginal ring containing 200mg dapivirine (DPV) and 320mg levonorgestrel (LNG) designed for 90-day use. MTN-030/IPM 041 compared the DPV/LNG ring to a DPV-only ring (200mg) over 14 days of use. MTN-044/IPM 053/CCN019 compared continuous or cyclic use of the DPV/LNG ring over 90 days of use. Safety was assessed by recording adverse events (AEs). DPV and LNG concentrations were quantified in plasma, cervicovaginal fluid, and cervical tissue. Vaginal bleeding was self-reported. RESULTS There were no differences in the proportion of participants with grade ≥2 genitourinary AEs or grade ≥3 AEs with DPV/LNG ring vs. DPV ring use (p = .22), or with DPV/LNG ring continuous vs. cyclic use (p = .67). Higher plasma DPV concentrations were observed in users of DPV/LNG compared to DPV-only rings (Cmax p = 0.049; AUC p = 0.091). Plasma DPV and LNG concentrations were comparable with continuous and cyclic use (Cmax p = 0.74; AUC p = 0.25). With cyclic use, median nadir plasma DPV concentration was approximately 300 pg/mL two days after removal and median t1/2 for cervicovaginal fluid DPV concentration was 5.76 hours (n = 3). Overall bleeding experiences did not differ between continuous and cyclic users (p = 0.12). CONCLUSIONS The extended duration DPV/ LNG rings were well tolerated and the observed DPV concentrations in plasma and cervicovaginal fluid when used continuously exceeded concentrations observed in previous DPV ring efficacy studies. LNG concentrations in plasma were comparable with other efficacious LNG-based contraceptives. Genital DPV concentrations had a short half-life and were thus not well sustained following ring removal.
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Affiliation(s)
- Sharon L. Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, United States of America
| | - Clifton W. Kelly
- Statistical Center for HIV/AIDS Research & Prevention, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Craig J. Hoesley
- University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, United States of America
| | - Diana L. Blithe
- National Institute of Child Health and Human Development, Contraceptive Development Program, DIPHR, NIH, Bethesda, Maryland, United States of America
| | - Jill Brown
- National Institute of Child Health and Human Development, Contraceptive Development Program, DIPHR, NIH, Bethesda, Maryland, United States of America
| | - Barbra A. Richardson
- Statistical Center for HIV/AIDS Research & Prevention, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
| | - Brid Devlin
- International Partnership for Microbicides, Silver Spring, Maryland, United States of America
| | - Craig W. Hendrix
- Department of Medicine, Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Samuel M. Poloyac
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mark A. Marzinke
- Department of Medicine, Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Holly Gundacker
- Statistical Center for HIV/AIDS Research & Prevention, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Devika Singh
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, United States of America
| | - Jeanna M. Piper
- National Institutes of Allergy and Infectious Disease, NIH, Bethesda, Maryland
| | - Sherri Johnson
- FHI 360, Durham, North Carolina, United States of America
| | - John Steytler
- International Partnership for Microbicides, Silver Spring, Maryland, United States of America
| | - Beatrice A. Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, United States of America
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Mukherjee A, Roy S. Pulmonary Embolism With Pulmonary Infarction in a Patient Using the Annovera® Segesterone Acetate and Ethinylestradiol Combined Vaginal Contraceptive Ring. Cureus 2024; 16:e63129. [PMID: 39055459 PMCID: PMC11271816 DOI: 10.7759/cureus.63129] [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] [Accepted: 06/25/2024] [Indexed: 07/27/2024] Open
Abstract
Combined hormonal contraceptives (CHC) are a very popular form of contraception among young women. Recently, vaginal contraceptive rings (VCR) have been formulated, offering greater convenience and ease of use. Venous thromboembolism (VTE) has been associated with CHC use and is a significant cause of mortality and morbidity in women. Here, we present the case of a 48-year-old woman who presented with right upper quadrant abdominal pain for four days associated with one day of shortness of breath. She had a history of anemia and abnormal uterine bleeding due to uterine fibroids. She was found to have a large embolus in the right pulmonary artery, associated with a right lower lobe pulmonary infarction. No evidence of lower-extremity deep venous thrombosis was found. She was using a segesterone acetate and ethinylestradiol combination VCR, which was removed. She was started on intravenous heparin anticoagulation with improvement in symptoms. This was later transitioned to an oral apixaban regimen prior to discharge. The exact mechanism of CHC-induced thrombotic risk remains unclear. They affect numerous proteins involved in the coagulation, anticoagulation, and thrombolytic pathways, thereby expressing their net thrombogenic potential. Estrogens have often been implicated as the more thrombogenic hormone, with progestogens being added to mitigate some of the risks. CHC use can cause a sixfold increased risk for VTE. Reducing the dose of estrogen and proper patient selection with attention to their risk profile remain essential for the safe use of these agents. This represents the first case report relating segesterone acetate and ethinylestradiol combination VCR to pulmonary embolism and infarction.
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Affiliation(s)
- Aveek Mukherjee
- Pulmonary Critical Care, University of Tennessee Health Science Center, Memphis, USA
| | - Sasmit Roy
- Nephrology, University of Virginia, Lynchburg, USA
- Nephrology, Liberty University Medical School, Lynchburg, USA
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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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Sitruk-Ware R, Sussman H, Brinton R, Schumacher M, Singer P, Kumar N, De Nicola AF, El-Etr M, Guennoun R, V Borlongan C. Nestorone (segesterone acetate) effects on neuroregeneration. Front Neuroendocrinol 2024; 73:101136. [PMID: 38670433 DOI: 10.1016/j.yfrne.2024.101136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/08/2024] [Accepted: 04/22/2024] [Indexed: 04/28/2024]
Abstract
Nestorone® (segesterone acetate) is a progestin with a chemical structure closely related to progesterone with high affinity and selectivity for the progesterone receptor without significant interaction with other steroid receptors. It has been developed for female and male contraception and is FDA-approved in a first long-acting contraceptive vaginal system for female contraception. Its safety has been extensively demonstrated in both preclinical and clinical studies for contraceptive indications. Nestorone was found to display neuroprotective and neuroregenerative activity in animal models of various central nervous system diseases, including multiple sclerosis, stroke, and amyotrophic lateral sclerosis. Reviewed herein are neuroprotective and myelin- regenerating properties of Nestorone in various animal models and its translational potential as a therapeutic agent for debilitating neurological diseases for which limited therapeutic options are available (Table 1).
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Affiliation(s)
| | | | - Roberta Brinton
- Center for Innovation in Brain Science, Tucson, AZ, United States
| | | | | | | | | | - Martine El-Etr
- U1195 Inserm and University Paris-Saclay Le Kremlin Bicêtre, France
| | - Rachida Guennoun
- U1195 Inserm and University Paris-Saclay Le Kremlin Bicêtre, France
| | - Cesar V Borlongan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Louwagie EJ, Quinn GFL, Pond KL, Hansen KA. Male contraception: narrative review of ongoing research. Basic Clin Androl 2023; 33:30. [PMID: 37940863 PMCID: PMC10634021 DOI: 10.1186/s12610-023-00204-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/26/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Since the release of the combined oral contraceptive pill in 1960, women have shouldered the burden of contraception and family planning. Over 60 years later, this is still the case as the only practical, effective contraceptive options available to men are condoms and vasectomy. However, there are now a variety of promising hormonal and non-hormonal male contraceptive options being studied. The purpose of this narrative review is to provide clinicians and laypeople with focused, up-to-date descriptions of novel strategies and targets for male contraception. We include a cautiously optimistic discussion of benefits and potential drawbacks, highlighting several methods in preclinical and clinical stages of development. RESULTS As of June 2023, two hormonal male contraceptive methods are undergoing phase II clinical trials for safety and efficacy. A large-scale, international phase IIb trial investigating efficacy of transdermal segesterone acetate (Nestorone) plus testosterone gel has enrolled over 460 couples with completion estimated for late 2024. A second hormonal method, dimethandrolone undecanoate, is in two clinical trials focusing on safety, pharmacodynamics, suppression of spermatogenesis and hormones; the first of these two is estimated for completion in December 2024. There are also several non-hormonal methods with strong potential in preclinical stages of development. CONCLUSIONS There exist several hurdles to novel male contraception. Therapeutic development takes decades of time, meticulous work, and financial investment, but with so many strong candidates it is our hope that there will soon be several safe, effective, and reversible contraceptive options available to male patients.
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Affiliation(s)
- Eli J Louwagie
- University of South Dakota Sanford School of Medicine, 1400 W 22nd St, Sioux Falls, SD, 57105, USA.
| | - Garrett F L Quinn
- University of South Dakota Sanford School of Medicine, 1400 W 22nd St, Sioux Falls, SD, 57105, USA
| | - Kristi L Pond
- University of South Dakota Sanford School of Medicine, 1400 W 22nd St, Sioux Falls, SD, 57105, USA
| | - Keith A Hansen
- Chair and Professor, Dept. of Obstetrics and Gynecology, University of South Dakota Sanford School of Medicine; Reproductive Endocrinologist, Sanford Fertility and Reproductive Medicine, 1500 W 22nd St Suite 102, Sioux Falls, SD, 57105, USA
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Renke G, Callizo C, Paes R, Antunes M, Michels G, Concha L, Almeida O, Valente C, Baesso T, Giovannoni B. Clinical Approaches to Nestorone Subdermal Implant Therapy in Women's Health. Biomedicines 2023; 11:2586. [PMID: 37761027 PMCID: PMC10526950 DOI: 10.3390/biomedicines11092586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Segesterone acetate (SA) or Nestorone, a fourth-generation progestogen, is a synthetic compound with high progestational activity and no androgenic, glucocorticoid, or anabolic effects. However, due to its oral inactivity, SA must be used by other routes, such as subcutaneous. Thus, considering its peculiar properties, the SA subdermal implant is successfully used in female contraception and postmenopausal hormone replacement therapy (HRT). In recent years, its potential uses in endometriosis, polycystic ovaries syndrome (PCOS), and a new therapeutic possibility for neuroprotection have made this treatment extremely interesting. However, the absence of a standardized dose and the long-term safety of SA implant therapy in women is still controversial. Here, we present the possible indications, doses, limitations, and side effects of SA implant therapy.
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Affiliation(s)
- Guilherme Renke
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
- Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Consuelo Callizo
- Centro de Pesquisa e Assistência em Reprodução Humana, Salvador 40210-341, Brazil
| | - Raphaela Paes
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Mariana Antunes
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Glaycon Michels
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Luana Concha
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Ordânio Almeida
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Christiane Valente
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Thomaz Baesso
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Bruna Giovannoni
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
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Cordova-Gomez A, Wong AP, Sims LB, Doncel GF, Dorflinger LJ. Potential biomarkers to predict return to fertility after discontinuation of female contraceptives-looking to the future. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1210083. [PMID: 37674657 PMCID: PMC10477712 DOI: 10.3389/frph.2023.1210083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/18/2023] [Indexed: 09/08/2023] Open
Abstract
Nowadays there are multiple types of contraceptive methods, from reversible to permanent, for those choosing to delay pregnancy. Misconceptions about contraception and infertility are a key factor for discontinuation or the uptake of family planning methods. Regaining fertility (the ability to conceive) after contraceptive discontinuation is therefore pivotal. Technical studies to date have evaluated return to fertility by assessing pregnancy as an outcome, with variable results, or return to ovulation as a surrogate measure by assessing hormone levels (such as progesterone, LH, FSH) with or without transvaginal ultrasound. In general, relying on time to pregnancy as an indicator of return to fertility following contraceptive method discontinuation can be problematic due to variable factors independent of contraceptive effects on fertility, hormone clearance, and fertility recovery. Since the ability to conceive after contraceptive method discontinuation is a critical factor influencing product uptake, it is important to have robust biomarkers that easily and accurately predict the timing of fertility return following contraception and isolate that recovery from extrinsic and circumstantial factors. The main aim of this review is to summarize the current approaches, existing knowledge, and gaps in methods of evaluating return-to-fertility as well as to provide insights into the potential of new biomarkers to more accurately predict fertility restoration after contraceptive discontinuation. Biomarker candidates proposed in this document include those associated with folliculogenesis, cumulus cell expansion, follicular rupture and ovulation, and endometrial transport and receptivity which have been selected and scored on predefined criteria meant to evaluate their probable viability for advancement. The review also describes limitations, regulatory requirements, and a potential path to clinically testing these selected biomarkers. It is important to understand fertility restoration after contraceptive method discontinuation to provide users and health providers with accurate evidence-based information. Predictive biomarkers, if easy and low-cost, have the potential to enable robust evaluation of RTF, and provide potential users the information they desire when selecting a contraceptive method. This could lead to expanded uptake and continuation of modern contraception and inform the development of new contraceptive methods to widen user's family planning choices.
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Affiliation(s)
- Amanda Cordova-Gomez
- Office of Population and Reproductive Health, USAID/Public Health Institute, Washington, DC, United States
| | - Andrew P. Wong
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Lee B. Sims
- Office of Population and Reproductive Health, USAID/Public Health Institute, Washington, DC, United States
| | - Gustavo F. Doncel
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Laneta J. Dorflinger
- Department of Product Development and Introduction, FHI 360, Durham, NC, United States
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Jensen JT, Archer DF, Westhoff CL, Nelson AL, Graham S, Bernick B. Satisfaction with a Segesterone Acetate and Ethinyl Estradiol Contraceptive Vaginal System Among Recent Oral Contraceptive or Hormonal Contraceptive Vaginal Ring Users. J Womens Health (Larchmt) 2023; 32:808-815. [PMID: 37253139 DOI: 10.1089/jwh.2022.0264] [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] [Indexed: 06/01/2023] Open
Abstract
Background: We evaluated satisfaction with use of a segesterone acetate and ethinyl estradiol (0.15/0.013 mg) contraceptive vaginal system (CVS) among women who had recently used a monthly contraceptive vaginal ring or contraceptive pills. The CVS is a ring-shaped device used in a 21-days-in/7-days-out regimen for 13 cycles. Materials and Methods: We analyzed post hoc satisfaction responses at cycle 3 and end of study (EOS) from a subset of participants with documented recent use of the monthly ring or daily pills before enrollment in a multinational, phase 3, 13-cycle trial evaluating the CVS. EOS included results from participants who had completed ≥10 cycles. Results were summarized descriptively. Results: We identified 128 recent ring and 219 recent pill users at cycle 3 (of 1033 survey participants), and 92 and 148, respectively, at EOS (of 622 survey participants); overall satisfaction with CVS use was high (≥90%). At EOS, most ring (89%) and pill (97%) users liked the CVS as much/better than any previous method. The two most-liked CVS features included ease of use and 1-year duration; the two most disliked features included ring insertion and feeling it coming out. At EOS, ≥88% of both groups reported no concern about using the same CVS for a year, and most (>80%) had recommended it to friends or family members. Conclusion: The CVS clinical trial participants who were recent ring/pill users reported high satisfaction and liked it as much/better than any previously used contraceptive; the CVS may be a good contraceptive option for switchers. Clinical trial registration NCT00263341.
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Affiliation(s)
- Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
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Al-Haddad S, Branham KKR, Clare CA. Advances in contraception: vaginal contraceptive rings. Ther Adv Reprod Health 2023; 17:26334941231186733. [PMID: 37465002 PMCID: PMC10350750 DOI: 10.1177/26334941231186733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 06/19/2023] [Indexed: 07/20/2023] Open
Abstract
The vaginal contraceptive ring is very effective and user dependent. In this article, we will discuss the different types of vaginal contraceptive rings, namely, the etonogestrel/ethinyl estradiol (ENG/EE) ring (NuvaRing, Merck, Rahway, NJ, USA) and the segesterone acetate (SA)/EE (Annovera, Mayne Pharma, Raleigh, NC, USA) ring. The details of dosing and administration, indications, advantages, disadvantages, and cost-effectiveness are presented. This literature review was conducted using PubMed and Google Scholar. The search terms included 'vaginal contraceptive ring', 'etonogestrel/ethinyl estradiol ring', and 'segesterone acetate/ethinyl estradiol ring'. The search was then sorted by year from 2000 until present, and the most recent articles were reviewed. The purpose of this article is to provide a comprehensive reference on the two vaginal contraceptive rings widely used in the United States for clinicians to guide management. Both vaginal contraceptive rings are combination of hormonal contraceptives that suppress ovulation and create physiologic conditions unfavorable for pregnancy. The ENG/EE ring is designed to be replaced monthly, while the SA/EE ring is a single device used over the course of 1 year. Common side effects of both devices include headaches, nausea, vomiting, and vaginitis. Serious adverse reactions can occur with the vaginal contraceptive rings including venous thromboembolism, psychiatric events, and hypersensitivity. Both devices are contraindicated in patients at high risk for arterial or venous thrombotic events, patients with a history of breast cancer or other estrogen/progesterone cancers, and patients with severe liver disease. Overall, the vaginal contraceptive ring is well tolerated and liked by patients. Patients should be well counseled on known severe adverse reactions. The vaginal contraceptive ring is more expensive than other forms of contraception and this should be an important point of discussion with patients.
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Affiliation(s)
| | - Ki’ara K. R. Branham
- Department of Obstetrics and Gynecology, Meharry Medical College, Nashville, TN, USA
| | - Camille A. Clare
- Department of Obstetrics and Gynecology, Downstate Health Sciences University, Brooklyn, NY, USA
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Jensen JT, Kaunitz AM, Achilles SL, Zatik J, Weyers S, Piltonen T, Suturina L, Apolikhina I, Bouchard C, Chen MJ, Apter D, Jost M, Foidart JM, Creinin MD. Pooled efficacy results of estetrol/drospirenone combined oral contraception phase 3 trials. Contraception 2022; 116:37-43. [PMID: 35921870 DOI: 10.1016/j.contraception.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/15/2022] [Accepted: 07/22/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate overall and subgroup efficacy of an estetrol (E4) 15 mg drospirenone (DRSP) 3 mg oral contraceptive in a 24/4-day regimen. STUDY DESIGN We pooled efficacy outcomes from 2 pivotal phase 3 contraceptive trials with E4/DRSP conducted in the United States/Canada and Europe/Russia. We assessed Pearl Index (PI; pregnancies per 100 participant-years) and 13-cycle life-table pregnancy rates in at-risk cycles (confirmed intercourse and no other contraceptive use) among participants 16 to 35 years. We calculated PI by age and further subcategorization (contraceptive history and body mass index [BMI]). We performed multivariable analysis using Cox regression to assess impact of potential confounding factors. RESULTS Analyses included 3027 participants, of whom 451 (14.9%) had a BMI ≥30 kg/m2. The pooled PI was 1.52 (95% confidence interval 1.04-2.16) and the 13-cycle life-table pregnancy rate was 1.28% (0.83%-1.73%). We calculated unadjusted pooled PI in participants 16 to 25 years and 26 to 35 years of 1.61 (0.94-2.57) and 1.43 (0.78-2.40), respectively; in new starters and switchers of 1.88 (1.09-3.00) and 1.24 (0.68-2.08), respectively; and by BMI <25 kg/m2, 25 to 29.9 kg/m2, and ≥30 kg/m2 of 1.14 (0.64-1.88), 2.19 (1.05-4.03), and 2.27 (0.83-4.94), respectively. In multivariable analysis, we found associations of prior pregnancy (hazard ratio [HR] 3.61[1.56-8.38]), Black race (HR 4.61[1.97-10.80]), age 16 to 25 years (HR 2.37[1.09-5.15]) and compliance <99% of expected pills (HR 4.21[2.04-8.66]) with conception. CONCLUSION E4/DRSP is an effective oral contraceptive overall and across subgroups stratified by age, contraceptive history, and BMI. Other than compliance, predictors of contraceptive failure are nonmodifiable. IMPLICATIONS STATEMENT Pooled results from two phase 3 trials demonstrate high contraceptive efficacy of the novel estetrol-drospirenone oral contraceptive. Several non-modifiable risk factors, including prior pregnancy, race, and age, are associated with higher pregnancy risk. Additional research is needed to better understand predictors of combined oral contraceptive failure.
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Affiliation(s)
- Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh and Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - János Zatik
- Szent Anna Szuleszeti, Nogyogyaszati es Ultrahang Maganrendelo, Debrecen, Hungary
| | - Steven Weyers
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium
| | - Terhi Piltonen
- Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Centre, Oulu University Hospital, Oulu, Finland
| | - Larisa Suturina
- Department of Reproductive Health Protection, Scientific Center for Family Health and Human Reproduction, Irkutsk, Russia
| | - Inna Apolikhina
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Named after Academician V.I. Kulakov of Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Céline Bouchard
- Clinique de Recherche en Santé de la femme (RSF) Inc., Québec City, Québec, Canada
| | - Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Dan Apter
- VL-Medi Clinical Research Center, Helsinki, Finland
| | - Maud Jost
- Estetra SRL, an affiliated company of Mithra Pharmaceuticals, Liège, Belgium.
| | - Jean-Michel Foidart
- Estetra SRL, an affiliated company of Mithra Pharmaceuticals, Liège, Belgium; Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
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McNamee K, Edelman A, Li RHW, Kaur S, Bateson D. Best Practice Contraception Care for Women with Obesity: A Review of Current Evidence. Semin Reprod Med 2022; 40:246-257. [PMID: 36746158 DOI: 10.1055/s-0042-1760214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of obesity among females of reproductive age is increasing globally. Access to the complete range of appropriate contraceptive options is essential for upholding the reproductive rights of this population group. People with obesity can experience stigma and discrimination when seeking healthcare, and despite limited evidence for provider bias in the context of contraception, awareness for its potential at an individual provider and health systems level is essential. While use of some hormonal contraceptives may be restricted due to increased health risks in people with obesity, some methods provide noncontraceptive benefits including a reduced risk of endometrial cancer and a reduction in heavy menstrual bleeding which are more prevalent among individuals with obesity. In addition to examining systems-based approaches which facilitate the provision of inclusive contraceptive care, including long-acting reversible contraceptives which require procedural considerations, this article reviews current evidence on method-specific advantages and disadvantages for people with obesity to guide practice and policy.
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Affiliation(s)
| | - Alison Edelman
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Raymond Hang Wun Li
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Simranvir Kaur
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
| | - Deborah Bateson
- Faculty of Medicine and Health, Daffodil Centre, University of Sydney, Sydney, Australia
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Abstract
Rates of unplanned pregnancies are high globally, burdening women and families. Efforts to develop male contraceptive agents have been thwarted by unacceptable failure rates, side effects and a dearth of pharmaceutical industry involvement. Hormonal male contraception consists of exogenous androgens which exert negative feedback on the hypothalamic-pituitary-gonadal axis and suppress gonadotropin production. This in turn suppresses testicular testosterone production and sperm maturation. Addition of a progestin suppresses spermatogenesis more effectively in men. Contraceptive efficacy studies in couples have shown male hormonal methods are effective and reversible, but also may come with side effects related to sexual desire, acne and serum cholesterol and inconvenient methods of dosing and delivery. Recently, novel androgens as potential contraceptive agents are being evaluated in early clinical trials and look to overcome these drawbacks. Here we summarize landmark studies of prototype male hormonal contraceptives, showcasing recent advances and future prospects in this important area of public health.
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Affiliation(s)
- Arthi Thirumalai
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA.
| | - Stephanie T Page
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA.
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Abstract
Estetrol/drospirenone is a combined oral contraceptive (COC) with a plant-synthesised foetal oestrogen (estetrol) and a well-established progestin (drospirenone). In preclinical models, estetrol has lower binding affinity for the oestrogen receptor-α (ER-α) in contrast to estradiol and has antagonistic properties against membrane ER-α in several tissues, including the breast, while retaining agonistic activity on receptors located in the nucleus. The low oestrogenicity of estetrol may potentially contribute to reduced thrombotic risk. Estetrol/drospirenone was an effective contraceptive in phase II and III clinical trials, with regular and predictable bleeding cycles maintained in the majority of women. Estetrol/drospirenone was generally well-tolerated with metrorrhagia reported as the most common treatment-related adverse event, which is consistent with other COCs. Cases of migraines with aura (or severe migraines), deep vein thrombosis, hyperkalaemia and depression were rarely reported during the phase III trials. Overall, estetrol/drospirenone is an effective and generally well-tolerated COC, with a potentially reduced risk of thrombosis. In 2019, an estimated 44% of women aged 15–49 years worldwide used modern contraception methods, and in these women using modern methods, 18% used an oral contraceptive. Estetrol/drospirenone is a combined oral contraceptive (COC) which uses estetrol, a plant-synthesised oestrogen naturally produced by the human foetal liver during pregnancy, in combination with drospirenone, a well-known progestin. Combined, these hormones suppress ovulation, which constitutes their primary mode of action in preventing pregnancy. As estetrol has weaker oestrogen-related effects, it may potentially reduce the risk for blood clots. Estetrol/drospirenone was an effective contraceptive in clinical trials, and most women had regular and predictable bleeding cycles. Metrorrhagia (i.e. abnormal bleeding) was the most commonly reported treatment-related adverse effect; however, this is a common issue with hormonal contraceptives. Cases of severe migraine headaches, deep vein thrombosis, high potassium levels or depression were rarely reported during clinical trials. Estetrol/drospirenone is an effective oral contraceptive, which may offer a contraceptive option with a lower risk for blood clots. However, further research is required to confirm the reduced risk of clotting.
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Ridgeway K, Montgomery ET, Smith K, Torjesen K, van der Straten A, Achilles SL, Griffin JB. Vaginal ring acceptability: A systematic review and meta-analysis of vaginal ring experiences from around the world. Contraception 2022; 106:16-33. [PMID: 34644609 PMCID: PMC9128798 DOI: 10.1016/j.contraception.2021.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The vaginal ring (ring) is a female-initiated, long-acting drug delivery system for different indications, including HIV prevention. Our aim was to provide evidence for acceptability of the vaginal ring across indications to support dapivirine and multipurpose prevention technology ring introduction and roll out. STUDY DESIGN This systematic review and meta-analysis followed PRISMA guidelines. We searched PubMed, Web of Science, Embase, and grey literature for publications reporting favorable ring acceptability and secondary outcomes involving actual ring use (comfort, ease of ring use, ring comfort during sex, expulsions, and vaginal symptoms) or hypothetical acceptability for any indication published January 1, 1970-June 15, 2021. We estimated random-effects pooled prevalence, assessing between-study variation using meta-regression. RESULTS Of 2,234 records, we included 123 studies with 40,434 actual and hypothetical ring users. The primary outcome assessment included 50 studies with 60 ring subgroups totaling 19,271 ring users. The favorable acceptability pooled prevalence was 85.6% (95%CI 81.3, 89.0), while hypothetical acceptability among non-ring users was 27.6% (95%CI 17.5, 40.5). In meta-regression, acceptability was higher in menopause (95.4%; 95%CI 88.4, 98.2) compared to contraceptive rings (83.7%; 95%CI 75.6, 89.5). Acceptability was lower in pharmacokinetic studies (50%; 95%CI 22.1, 77.9) compared to RCTs (89.5%; 95%CI 85.8.92.4) and in studies assessing acceptability at ≥12 months (78.5%; 95%CI 66.5, 87.1) versus studies assessing acceptability at <3 months (91.9%; 95%CI 83.7, 96.1). European (90.6%; 95%CI 83.9, 94.7), Asian (97.1%; 95%CI 92.0, 99.0), and multi-region studies (93.5%; 95%CI 84.6, 97.4) reported more favorable acceptability compared to African studies (59.4%; 95%CI 38.3, 77.5). Secondary outcomes were similarly favorable, including ring comfort (92.9%; 95%CI 89.2, 95.4), ease of use (90.9%; 95%CI 86.5, 94.0), and comfort during sex (82.7%; 95%CI 76.4, 87.6). Limitations include inconsistent outcome definitions and unmeasured factors affecting acceptability. CONCLUSIONS Women who used vaginal rings reported they were acceptable across indications geographic regions and indications. Policy makers should consider the ring as an important option for pregnancy and HIV prevention drug development. IMPLICATIONS This review found favorable acceptability among vaginal ring users across indications and geographic areas, in contrast to low hypothetical acceptability among non-users. Vaginal rings are an important drug delivery system for pregnancy and HIV preventions, and scale-up should plan to address initial hesitancy among new users.
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Affiliation(s)
- Kathleen Ridgeway
- FHI 360, Global Health Population Nutrition, Durham, NC, United States
| | - Elizabeth T. Montgomery
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States,Center for AIDS Pervention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Kevin Smith
- Centre for Global Health, RTI International, Durham, NC, United States
| | - Kristine Torjesen
- FHI 360, Global Health Population Nutrition, Durham, NC, United States
| | - Ariane van der Straten
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States,Center for AIDS Pervention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Sharon L. Achilles
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States,Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Jennifer B. Griffin
- Centre for Global Health, RTI International, Durham, NC, United States,Corresponding author. J. B. Griffin, (J.B. Griffin)
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16
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Baker CC, Chen MJ. New Contraception Update — Annovera, Phexxi, Slynd, and Twirla. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022; 11:21-27. [PMID: 35795653 PMCID: PMC9255890 DOI: 10.1007/s13669-021-00321-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Purpose of Review
In this review, we discuss the efficacy, safety, and benefits of four new contraceptive products available in the USA, specifically Annovera, Phexxi, Slynd, and Twirla.
Recent Findings
Annovera is a vaginal ring releasing ethinyl estradiol and segesterone acetate that can be used for up to one year (13 cycles), offering patients an effective, user-controlled option that may improve contraceptive access for those in low-resource settings or those with barriers to retrieving monthly prescriptions; however, given limited efficacy and safety data in people with body mass index (BMI) > 29 kg/m2, clinicians may consider whether Annovera is an appropriate contraceptive method for obese patients if there are other acceptable alternatives. Phexxi prescription-only vaginal gel is a user-controlled, non-hormonal, on-demand contraceptive method that represents a novel addition to the market with its additional uses as a personal lubricant and as a potential microbicide for urogenital infection prevention. Slynd, a drospirenone-only pill, provides more flexibility for delayed or missed pills while maintaining efficacy and a more favorable bleeding profile compared with previously available progestin-only pills. Lastly, Twirla is a transdermal patch releasing ethinyl estradiol and levonorgestrel that offers users an additional option for a user-controlled, combined hormonal contraceptive method without daily dosing; however, prescription is limited to patients with BMI < 30 kg/m2 due to decreased efficacy and VTE events in people with obesity.
Summary
The addition of these products expands the available options for pregnancy prevention to address unmet contraceptive needs.
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Affiliation(s)
- Courtney C. Baker
- Department of Obstetrics and Gynecology, University of California, Davis, 4860 Y Street, Suite 2500, Sacramento, CA 95817, USA
| | - Melissa J. Chen
- Department of Obstetrics and Gynecology, University of California, Davis, 4860 Y Street, Suite 2500, Sacramento, CA 95817, USA
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17
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Sitruk-Ware R. [New frontiers in contraception research]. Med Sci (Paris) 2021; 37:1014-1020. [PMID: 34851278 DOI: 10.1051/medsci/2021163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Improving current contraceptives and discover novel methods easy to use with added health benefits would meet the needs of couples who seek alternatives to current methods. New delivery systems target user-controlled, longer-acting options to provide choice, user's autonomy and improve compliance. Self-injections, microarray patches, pod rings able to deliver several molecules aim to prevent both pregnancies and sexually transmitted infections. Improved intrauterine systems and non-surgical permanent methods are also on the research agenda. The search for novel methods must continue, to curb maternal mortality led by multiple pregnancies and unsafe abortion, still a burden in many countries.
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Affiliation(s)
- Régine Sitruk-Ware
- The Population Council, Center for Biomedical Research, 1230 York Avenue, New York, NY 10065, États-Unis
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18
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Verma N, Cwiak C, Kaunitz AM. Hormonal Contraception: Systemic Estrogen and Progestin Preparations. Clin Obstet Gynecol 2021; 64:721-738. [PMID: 34668886 DOI: 10.1097/grf.0000000000000634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Combined hormonal contraception (CHC) are short-acting, reversible methods containing both estrogen and progestin. Available CHC methods include combined oral contraceptives, transdermal patches, and vaginal rings. The combined oral contraceptive remains the most commonly used contraceptive method in the United States. The general principles of CHC will be reviewed, including mechanism of action and effectiveness. Unless otherwise stated, these principles apply to all CHCs. When discussing clinical studies and specific considerations related only to pills, patches, or rings, the method(s) will be specified. Words that specify sex are used when discussing studies in which sex was specified.
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Affiliation(s)
- Nisha Verma
- Department of GYN/OB, Emory University School of Medicine, Atlanta, Georgia
| | - Carrie Cwiak
- Department of GYN/OB, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew M Kaunitz
- Department of Obstetrics & Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
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19
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Li L, Gatto GJ, Brand RM, Krovi SA, Cottrell ML, Norton C, van der Straten A, Johnson LM. Long-acting biodegradable implant for sustained delivery of antiretrovirals (ARVs) and hormones. J Control Release 2021; 340:188-199. [PMID: 34678316 DOI: 10.1016/j.jconrel.2021.10.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 10/05/2021] [Accepted: 10/16/2021] [Indexed: 12/14/2022]
Abstract
Women worldwide confront two major reproductive health challenges: the need for contraception and protection from sexually transmitted infections, including Human Immunodeficiency Virus (HIV). Multipurpose Prevention Technologies (MPTs) that simultaneously prevent unintended pregnancy and HIV could address these challenges with a single product. Here, we developed a long-acting (LA) subcutaneously administered and biodegradable implant system that provides sustained delivery of contraceptive and antiretroviral (ARV) with zero-order release kinetics. The MPT system involves two implants comprising an extruded tube of a biodegradable polymer, poly(ε-caprolactone) (PCL). Each implant is filled with a formulation of progestin [levonorgestrel (LNG) or etonogestrel (ENG)], or a formulation of a potent ARV [tenofovir alafenamide (TAF), or 4'-Ethynyl-2-fluoro-2'-deoxyadenosine (EFdA)]. We demonstrated sustained in-vitro release of LNG, ENG, and EFdA from the implant system for 13-17 months, while maintaining high stability of the drugs (>99%) within the implant reservoirs. We further elucidated the controlled release mechanism of the implant and leveraged several tunable parameters (e.g., type and quantity of the excipient, PCL properties, and implant wall thickness) to tailor the release kinetics and enhance the mechanical integrity of the MPT implant. The optimized MPT showed sustained in-vitro release of ENG and EFdA over 1 year while maintaining a high level of formulation stability and structural integrity. The MPT implant system was further evaluated in a preclinical study using a rodent model and demonstrated sustained release of EFdA (6 months) and ENG (12 months) with high stability of the drug formulation (>95%). This manuscript supports the continued advancement of LA delivery systems for MPTs.
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Affiliation(s)
- Linying Li
- Biomedical Technologies Group, RTI International, Research Triangle Park, NC 27709, USA
| | - Gregory J Gatto
- Global Public Health Impact Center, RTI International, Research Triangle Park, NC 27709, USA
| | - Rhonda M Brand
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Sai Archana Krovi
- Biomedical Technologies Group, RTI International, Research Triangle Park, NC 27709, USA
| | - Mackenzie L Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Chasity Norton
- Biomedical Technologies Group, RTI International, Research Triangle Park, NC 27709, USA
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Dept of Medicine, University of California San Francisco, San Francisco, CA 94104, USA; ASTRA consulting, Kensington, CA 94708, USA
| | - Leah M Johnson
- Biomedical Technologies Group, RTI International, Research Triangle Park, NC 27709, USA.
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20
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Raidoo S, Pearlman Shapiro M, Kaneshiro B. Contraception in Adolescents. Semin Reprod Med 2021; 40:89-97. [PMID: 34500476 DOI: 10.1055/s-0041-1735629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Adolescents are at risk for unwanted pregnancy when they become sexually active, and contraception is an important part of mitigating this risk. Use of contraceptive methods, and long-acting reversible contraceptive methods such as implants and intrauterine devices in particular, has increased among adolescents. Although sexual activity has declined and contraceptive use has increased among adolescents in the United States in recent years, the unintended pregnancy rate remains high. All of the currently available contraceptive methods are safe and effective for adolescents to use; however, adolescents may have specific concerns about side effect profiles and unscheduled bleeding that should be addressed during contraceptive counseling. Healthcare providers should prioritize adolescents' needs and preferences when approaching contraceptive counseling, and also consider the unique access and confidentiality issues that adolescents face when accessing contraception.
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Affiliation(s)
- Shandhini Raidoo
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
| | - Marit Pearlman Shapiro
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
| | - Bliss Kaneshiro
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
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21
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Liu AY, Dominguez Islas C, Gundacker H, Neradilek B, Hoesley C, van der Straten A, Hendrix CW, Beamer M, Jacobson CE, McClure T, Harrell T, Bunge K, Devlin B, Nuttall J, Spence P, Steytler J, Piper JM, Marzinke MA. Phase 1 pharmacokinetics and safety study of extended duration dapivirine vaginal rings in the United States. J Int AIDS Soc 2021; 24:e25747. [PMID: 34118115 PMCID: PMC8196716 DOI: 10.1002/jia2.25747] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Vaginal rings are a promising approach to provide a woman-centred, long-acting HIV prevention strategy. Prior trials of a 25 mg dapivirine (DPV) ring have shown a favourable safety profile and approximately 30% risk reduction of HIV-1 infection. Extended duration rings replaced every three months may encourage user adherence, improve health service efficiency and reduce cost overall. We evaluated safety, pharmacokinetics, adherence and acceptability of two three-month rings with different DPV dosages, compared with the monthly DPV ring. METHODS From December 2017 to October 2018, MTN-036/IPM-047 enrolled 49 HIV-negative participant in Birmingham, Alabama and San Francisco, California into a phase 1, randomized trial comparing two extended duration (three-month) rings (100 or 200 mg DPV) to a monthly 25 mg DPV ring, each used over 13 weeks, with follow-up completed in January 2019. Safety was assessed by recording adverse events (AEs). DPV concentrations were quantified in plasma, cervicovaginal fluid (CVF) and cervical tissue, at nominal timepoints. Geometric mean ratios (GMRs) relative to the comparator ring were estimated from a regression model. RESULTS There were no differences in the proportion of participants with grade ≥2 genitourinary AEs or grade ≥3 AEs in the extended duration versus monthly ring arms (p = 1.0). Plasma and CVF DPV concentrations were higher in the extended duration rings compared to the monthly ring. Plasma GMRs were 1.31 to 1.85 and 1.41 to 1.86 and CVF GMRs were 1.45 to 2.87 and 1.74 to 2.60 for the 100 and 200 mg ring respectively. Cervical tissue concentrations were consistently higher in the 200 mg ring (GMRs 2.36 to 3.97). The majority of participants (82%) were fully adherent (ring inserted at all times, with no product discontinuations/outages) with no differences between the monthly versus three-month rings. Most participants found the ring acceptable (median = 8 on 10-point Likert scale), with a greater proportion of participants reporting high acceptability (9 or 10) in the 25 mg arm (73%) compared with the 100 mg (25%) and 200 mg (44%) arms (p = 0.01 and p = 0.15 respectively). CONCLUSIONS The extended duration DPV rings were well-tolerated and achieved higher DPV concentrations compared with the monthly DPV ring. These findings support further evaluation of three-month DPV rings for HIV prevention.
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Affiliation(s)
- Albert Y Liu
- Bridge HIVSan Francisco Department of Public HealthSan FranciscoCAUSA
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Clara Dominguez Islas
- Vaccine and Infectious Disease DivisionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Holly Gundacker
- Statistical Center for HIV/AIDS Research & PreventionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Blazej Neradilek
- Statistical Center for HIV/AIDS Research & PreventionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | | | - Ariane van der Straten
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Women’s Global Health Imperative (WGHI)RTI InternationalBerkeleyCAUSA
- ASTRA ConsultingKensingtonCAUSA
| | - Craig W Hendrix
- Division of Clinical PharmacologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - May Beamer
- Magee‐Womens Research InstitutePittsburghPAUSA
| | | | | | - Tanya Harrell
- Statistical Center for HIV/AIDS Research & PreventionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Katherine Bunge
- Magee‐Womens Research InstitutePittsburghPAUSA
- Department of Obstetrics, Gynecology, and Reproductive SciencesUniversity of PittsburghPittsburghPAUSA
| | - Brid Devlin
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - Jeremy Nuttall
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - Patrick Spence
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - John Steytler
- International Partnership for MicrobicidesSilver SpringMDUSA
| | - Jeanna M Piper
- Division of AIDSNational Institutes of HealthBethesdaMDUSA
| | - Mark A Marzinke
- Division of Clinical PharmacologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
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22
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Creinin MD, Westhoff CL, Bouchard C, Chen MJ, Jensen JT, Kaunitz AM, Achilles SL, Foidart JM, Archer DF. Estetrol-drospirenone combination oral contraceptive: North American phase 3 efficacy and safety results. Contraception 2021; 104:222-228. [PMID: 34000251 DOI: 10.1016/j.contraception.2021.05.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess efficacy, cycle control, and safety of an oral contraceptive containing estetrol (E4) 15 mg and drospirenone (DRSP) 3 mg. STUDY DESIGN Women aged 16 to 50 years with a body mass index ≤35 kg/m2 enrolled in this multicenter, open-label, 13-cycle, phase 3 trial evaluating E4/DRSP in a 24-active/4-placebo regimen. Follow-up was scheduled at Cycles 2, 4, 7, and 10 and within 3 weeks of completing Cycle 13. Participants used daily diaries to record pill use and vaginal bleeding. We evaluated efficacy outcomes in women 16 to 35 years and bleeding patterns and safety (adverse events [AEs]) in all participants. We assessed overall and method-failure pregnancy rates using the Pearl index (PI) and life-table analysis. Scheduled bleeding included spotting or bleeding starting during the 4-day placebo period or first 3 days of the next cycle. RESULTS We enrolled 1864 women of whom 1674 were 16 to 35 years. Women 16 to 35 years had a PI of 2.65 (95% CI 1.73-3.88), method-failure PI of 1.43 (95% CI 0.7-2.39) and 13-cycle life-table pregnancy rate of 2.1%. Scheduled bleeding occurred in 82.9% to 87.0% of women per cycle; median duration was 4.5 days. Unscheduled bleeding decreased from 30.3% in Cycle 1 to 21.3% to 22.1% during Cycles 2 to 4 and remained stable (15.5% to 19.2%) thereafter. The most frequently reported AEs were headache (5.0%) and metrorrhagia (4.6%). One-hundred thirty-two (7.1%) women discontinued the study early for an AE, most commonly for metrorrhagia (0.9%) and menorrhagia (0.8%). No thromboembolic events occurred. CONCLUSION E4/DRSP is an effective oral contraceptive with a predictable bleeding pattern for most women and low AE rates. IMPLICATIONS STATEMENT A new oral contraceptive with a novel estrogen, estetrol, combined with drospirenone has efficacy and safety within the range of other available oral contraceptives. Large phase 4 studies will be needed to confirm if this combination is associated with an improved adverse event profile or lower thrombosis risk.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, United States
| | - Céline Bouchard
- Clinique de Recherche en Santé des Femmes, Quebec City, QC, Canada
| | - Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida Jacksonville, Jacksonville, FL, United States
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh/Magee-Womens Hospital, Pittsburgh, PA, United States
| | - Jean-Michel Foidart
- Mithra Pharmaceuticals, Liège, Belgium; Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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Use of simulated vaginal and menstrual fluids to model in vivo discolouration of silicone elastomer vaginal rings. INTERNATIONAL JOURNAL OF PHARMACEUTICS-X 2021; 3:100081. [PMID: 34027386 PMCID: PMC8120934 DOI: 10.1016/j.ijpx.2021.100081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 01/13/2023]
Abstract
Vaginal rings releasing antiretrovirals – either alone or in combination with contraceptive progestins – are being developed for prevention of human immunodeficiency virus (HIV) transmission via vaginal sex. Following Phase I trials, significant discolouration was observed on the surface of investigational silicone elastomer antiretroviral-contraceptive matrix-type vaginal rings containing either 25 mg dapivirine or 200 mg dapivirine plus levonorgestrel. In this study, potential causes of the discolouration have been assessed in vitro using simulated vaginal and menstrual fluids (SVF and SMF, respectively) to model in vivo exposure. The fluid compositions also included hydrogen peroxide (H2O2), hydrogen peroxide plus a copper intrauterine device (IUD), or synthetic dyes (representing personal care and household cleaning products). No discolouration was observed for rings exposed to SVF + hydrogen peroxide (with or without an IUD). However, the SVF + dye compositions showed significant ring discolouration, with staining patterns similar to those observed with rings that had been exposed to highly-coloured personal care and household cleaning products during clinical trial use. Exposure of rings to SMF compositions invariably caused yellow surface discolouration, dark spotting and markings, similar to the staining patterns observed following clinical use. The darker marks on the ring surface were identified as blood debris derived from the SMF. The study indicates that surface discolouration of rings in vivo can be attributed to exposure to menstrual fluid or highly coloured personal care or household cleaning products. Discolouration of the rings was not associated with any specific safety risks for the user, though severe discolouration could potentially impact acceptability and adherence.
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Segesterone acetate serum levels with a regression model of continuous use of the segesterone acetate/ethinyl estradiol contraceptive vaginal system. Contraception 2021; 104:229-234. [PMID: 33785318 DOI: 10.1016/j.contraception.2021.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To predict serum segesterone (SA) and ethinyl estradiol (EE) levels after 364 days of hypothetical continuous use (without removal) of a cyclic contraceptive vaginal system (CVS) containing 0.15 mg SA and 0.013 mg EE. STUDY DESIGN We used pharmacokinetic (PK) data (n = 37) from a multicenter, open-label, nonrandomized study of healthy women (18-38 years) that used the CVS for 13 cycles in a 21 days-in/7 days-out regimen to develop a linear regression model to predict daily serum SA and EE levels for 364 days of continuous CVS use. We then determined residual SA/EE levels in vitro from 18 randomly chosen CVS used by women who completed 13 cycles. Serum SA and EE levels were also predicted for 364 days of continuous CVS use in another in vitro study. RESULTS After a hypothetical 364 days of continuous CVS use, we predicted daily mean serum levels to be 184 pmol/L (95% confidence interval [CI], 102‒332 pmol/L) for SA and 43 pmol/L (95% CI, 19‒95 pmol/L) for EE. We did predict that serum EE levels would not accumulate over time. Residual SA and EE in the CVS were 60% and 80% of the original load after 13 cycles, respectively. CONCLUSION The predicted serum SA level after 364 days of hypothetical continuous CVS use was comparable to reported levels at which no pregnancy occurred (>100 pmol/L), showing the potential of the CVS for one year of continuous use. Clinical trials on continuous CVS use are planned. IMPLICATIONS Based on statistical modeling, the long-term, user-controlled contraceptive vaginal system containing segesterone acetate and ethinyl estradiol may have the potential to provide effective pregnancy prevention if used continuously (without removal) for one year. Further investigation is warranted.
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Aragon FFH, Haeck CM, Morais PC, Variano B. Polymorphism characterization of segesterone acetate: A comprehensive study using XRPD, FT-IR and Raman spectroscopy. Int J Pharm 2021; 596:120234. [PMID: 33484926 DOI: 10.1016/j.ijpharm.2021.120234] [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: 10/14/2020] [Revised: 12/27/2020] [Accepted: 12/31/2020] [Indexed: 11/19/2022]
Abstract
Segesterone acetate (SA) is a promising and recently approved drug substance used as a contraceptive. SA has two major polymorphic forms, Form I and II. We have shown through indirect analysis that Form I is the more thermodynamically stable polymorphic form at room temperature, however, during the manufacturing process of SA drug products the solid-state stability must be shown to be under control. In the present work, a systematic study has been done using X-ray powder diffraction (XRPD), Fourier Transformed Infrared spectroscopy (FT-IR), and room temperature Raman spectroscopy on both micronized and non-micronized SA powder samples. XRPD showed a crystalline structure in both powder samples with a distinct coexistence of the polymorphic Forms I and II which was confirmed by FT-IR and Raman spectroscopy. The study showed that after thermal annealing a noticeable reduction of the amount of polymorphic Form II was found in both samples. Our results suggest the possibility of reducing the amount of SA Form II by thermal treatment inducing an irreversible solid-state transition to yield the thermodynamically more stable polymorphic Form I. To quantify the ratio of polymorphs I and II we have implemented a method that can be used as a routine analysis step in the manufacturing process of SA.
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Affiliation(s)
- Fermin F H Aragon
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Clement M Haeck
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Paulo C Morais
- Universidade Católica de Brasília, Brasília, DF 70790-160, Brazil; Universidade de Brasília, Instituto de Física, Brasília, DF 70910-900, Brazil
| | - Bruce Variano
- Center for Biomedical Research, Population Council, New York, NY, USA.
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Sitruk-Ware R, Bonsack B, Brinton R, Schumacher M, Kumar N, Lee JY, Castelli V, Corey S, Coats A, Sadanandan N, Gonzales-Portillo B, Heyck M, Shear A, Blaise C, Zhang H, Sheyner M, García-Sánchez J, Navarro L, El-Etr M, De Nicola AF, Borlongan CV. Progress in progestin-based therapies for neurological disorders. Neurosci Biobehav Rev 2020; 122:38-65. [PMID: 33359391 DOI: 10.1016/j.neubiorev.2020.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/26/2020] [Accepted: 12/12/2020] [Indexed: 12/16/2022]
Abstract
Hormone therapy, primarily progesterone and progestins, for central nervous system (CNS) disorders represents an emerging field of regenerative medicine. Following a failed clinical trial of progesterone for traumatic brain injury treatment, attention has shifted to the progestin Nestorone for its ability to potently and selectively transactivate progesterone receptors at relatively low doses, resulting in robust neurogenetic, remyelinating, and anti-inflammatory effects. That CNS disorders, including multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), spinal cord injury (SCI), and stroke, develop via demyelinating, cell death, and/or inflammatory pathological pathways advances Nestorone as an auspicious candidate for these disorders. Here, we assess the scientific and clinical progress over decades of research into progesterone, progestins, and Nestorone as neuroprotective agents in MS, ALS, SCI, and stroke. We also offer recommendations for optimizing timing, dosage, and route of the drug regimen, and identifying candidate patient populations, in advancing Nestorone to the clinic.
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Affiliation(s)
| | - Brooke Bonsack
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | | | | | - Jea-Young Lee
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Vanessa Castelli
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Sydney Corey
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Alexandreya Coats
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Nadia Sadanandan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Bella Gonzales-Portillo
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Matt Heyck
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Alex Shear
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Cozene Blaise
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Henry Zhang
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Michael Sheyner
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Julián García-Sánchez
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Lisset Navarro
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | | | - Cesar V Borlongan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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Nelson AL, Kaunitz AM, Kroll R, Simon JA, Poindexter AN, Castaño PM, Ackerman RT, Flood L, Chiodo JA, Garner EI. Efficacy, safety, and tolerability of a levonorgestrel/ethinyl estradiol transdermal delivery system: Phase 3 clinical trial results. Contraception 2020; 103:137-143. [PMID: 33259782 DOI: 10.1016/j.contraception.2020.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the contraceptive efficacy, safety, and tolerability of a contraceptive transdermal delivery system, (TDS; TWIRLAⓇ) containing levonorgestrel (LNG) and ethinyl estradiol (EE). STUDY DESIGN This single-arm, open-label, multicenter, 1-year (13 cycle), phase 3 study enrolled sexually active women ≥18 years old at risk for pregnancy irrespective of body mass index (BMI). Women used patches in 28-day cycles (3 consecutive administrations of 7-day patches followed by 7 days off-treatment/patch-free week). We assessed contraceptive efficacy by the Pearl Index (PI) in women 18 to 35 years, excluding cycles without intercourse or when other contraceptive methods were used. RESULTS The study enrolled 2032 demographically diverse women in the US, of which 35.3% had a BMI ≥30 kg/m2. In the primary efficacy analysis, the PI (95% confidence interval) was 5.8 (4.5-7.2) pregnancies per 100 woman-years. PIs trended higher as BMI increased; the PI was 4.3 (2.9-5.8) in women with BMI <30 kg/m2 and 8.6 (5.8-11.5) in women with BMI ≥30 kg/m2. Hormone-related treatment-emergent adverse events included nausea (4.1%) and headache (3.6%); 11% of women discontinued due to adverse events. Four women (all with BMIs ≥30 kg/m2) reported thromboembolic events considered related to treatment. CONCLUSIONS The low-dose LNG/EE TDS was effective in preventing pregnancy in a population of women representative of US demographics. Efficacy was reduced in women with BMI ≥30 kg/m2. The TDS safety and tolerability profile was consistent with other similar dose combined hormonal contraceptives. Results of this phase 3 study supported the US Food and Drug Administration approval of TWIRLAⓇ for prevention of pregnancy in women with BMI <30 kg/m2. IMPLICATIONS TDS (120 µg/day levonorgestrel and 30 µg/day ethinyl estradiol) is an effective, low-dose transdermal contraceptive patch with favorable tolerability profile approved for prevention of pregnancy in women with BMI <30 kg/m2. TDS has reduced effectiveness in women with BMI ≥30 kg/m2.
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Affiliation(s)
| | - Andrew M Kaunitz
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Robin Kroll
- University of Washington, Seattle Women's Health, Research, Gynecology, Seattle, WA, USA
| | - James A Simon
- George Washington University School of Medicine, Washington, DC, USA
| | | | - Paula M Castaño
- Columbia University Irving Medical Center, New York, NY, USA
| | | | - Lisa Flood
- ALK-Abello, Inc. Pharmaceuticals, Bedminster, NJ, USA
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Contraceptive technologies for global health: ethically getting to safe, effective and acceptable options for women and men. Drug Deliv Transl Res 2020; 10:299-303. [PMID: 32124414 PMCID: PMC7066088 DOI: 10.1007/s13346-020-00726-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
While the contributions of science, biomedicine, and engineering to contraceptive development offer wonder and promise to the community, what inspires many of us in the not-for-profit sector about the process of contraceptive product development is the integration of consultations with users, providers and policy makers, good clinical and manufacturing practice in product design and development, and the delivery of approved products at affordable prices to those in greatest need. The commitment to have an impact on the reproductive lives of women and men along with the ethical principles embedded in this process of achieving safe, effective, and acceptable options include the respect for persons, i.e., eventual users, beneficence for those using the product and justice in ensuring that it is available to those who are most vulnerable, including those in developing countries. It is the inspiration that drives the scientists and developers to produce public benefit and additional social value.
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Abstract
PURPOSE OF REVIEW In the past few years, there have been great advances in contraceptive technology and development. Here we review advances in contraception over the past two years including new medications, and technologies. RECENT FINDINGS Contraception must be discussed within the context of individual goals and context. New contraceptive options approved by the FDA in the past two years include a year-long vaginal ring, a progestin-only pill that is as effective as combined oral contraceptive pills, a new hormonal patch and a vaginal gel that may also help prevent sexually transmitted infections.There are still areas of contraceptive research that are very much unknown including biomarkers of contraceptive efficacy or side effects, how individuals or groups metabolize contraception, initiation around reproductive life events or the discontinuation of other methods. SUMMARY There have been many new contraceptives developed over the past few years to address challenges of existing contraception and create new methods; yet, there remain many unanswered questions in contraceptive research. Contraceptive technology has far-reaching consequences, and independent of technology itself, represents a great opportunity for truly personalized medicine.
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Long-Lasting, Patient-Controlled, Procedure-Free Contraception: A Review of Annovera with a Pharmacist Perspective. PHARMACY 2020; 8:pharmacy8030156. [PMID: 32872116 PMCID: PMC7558341 DOI: 10.3390/pharmacy8030156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 11/22/2022] Open
Abstract
Annovera (segesterone acetate and ethinyl estradiol vaginal system) is a US Food and Drug Administration FDA-approved long-lasting, reversible contraceptive that is fully administered by the user and does not require a procedure for insertion or removal. The vaginal system is in the shape of a ring and contains low doses of a novel progestin, egesterone acetate, and ethinyl estradiol. It is made of silicone and is fully pliable and flexible. The vaginal system is reusable for 13 cycles, using a 21 days in/7 days out regimen, providing women with the ability to control their fertility. Particularly now during the COVID-19 pandemic when access to contraception has been further reduced, patients may benefit from a method that is both long-lasting and patient-controlled.
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Thomas MA, Chappell BT, Maximos B, Culwell KR, Dart C, Howard B. A novel vaginal pH regulator: results from the phase 3 AMPOWER contraception clinical trial. Contracept X 2020; 2:100031. [PMID: 32685920 PMCID: PMC7358659 DOI: 10.1016/j.conx.2020.100031] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/18/2020] [Accepted: 06/21/2020] [Indexed: 11/27/2022] Open
Abstract
Objective The objective was to evaluate the contraceptive effectiveness, safety, and acceptability of a novel vaginal pH regulator over seven cycles of use. Study design A single-arm, open-label, phase 3 study was conducted across 112 sites in the United States in sexually active 18–35-year-old women at risk of pregnancy. Women administered the study treatment ≤ 1 h before each episode of intercourse. Women recorded use of study drug, coital information, and any symptoms experienced in electronic diaries. The primary outcome was the seven-cycle cumulative pregnancy rate as calculated using the Kaplan–Meier methodology; secondary outcomes included safety. Overall satisfaction was assessed via written questionnaires. Results A total of 1384 women were enrolled in the study from July 2017 to November 2018. Mean age was 27.7 ± 4.4 years; most women were white (69.0%). The seven-cycle cumulative pregnancy percentage was 13.7% [95% confidence interval (CI): 10.0%–17.5%], meeting the prespecified primary endpoint of having the upper bound 95% CI ≤ 21%. Most common adverse events (AEs) occurring in ≥ 2% of women were vulvovaginal burning sensation, vulvovaginal pruritus, urinary tract infection, vulvovaginal pain, mycotic infection, bacterial vaginosis, and nasopharyngitis. Of 1330 women who used the study drug at least once, fewer than 2% of women discontinued due to any AEs, and < 1% of women discontinued due to genitourinary symptoms. Overall, > 80% of women reported being “very satisfied” or “satisfied” with study treatment. Conclusions In this phase 3 study, the novel vaginal pH regulator demonstrated 86.3% contraceptive effectiveness, was safe and well tolerated, and was highly acceptable. Implications This novel vaginal pH regulator is a safe, nonhormonal, woman-controlled method of contraception that expands women's options.
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Affiliation(s)
- Michael A Thomas
- University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45219, USA
| | - B Todd Chappell
- Adams Patterson Gynecology & Obstetrics, 1727 Kirby Parkway, Memphis, TN, 38210, USA
| | - Bassem Maximos
- Maximos Obstetrics and Gynecology, 651 Egret Bay Boulevard, League City, TX, 77573, USA
| | - Kelly R Culwell
- Evofem Biosciences, Inc., 12400 High Bluff Drive, Suite 600, San Diego, CA, 92130, USA
| | - Clint Dart
- Health Decisions, 2510 Meridian Parkway, Durham, NC, 27713, USA
| | - Brandon Howard
- Evofem Biosciences, Inc., 12400 High Bluff Drive, Suite 600, San Diego, CA, 92130, USA
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Chen MJ, Creinin MD, Turok DK, Archer DF, Barnhart KT, Westhoff CL, Thomas MA, Jensen JT, Variano B, Sitruk-Ware R, Shanker A, Long J, Blithe DL. Dose-finding study of a 90-day contraceptive vaginal ring releasing estradiol and segesterone acetate. Contraception 2020; 102:168-173. [PMID: 32416145 DOI: 10.1016/j.contraception.2020.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate serum estradiol (E2) concentrations during use of 90-day contraceptive vaginal rings releasing E2 75, 100, or 200 mcg/day and segesterone acetate (SA) 200 mcg/day to identify a dose that avoids hypoestrogenism. STUDY DESIGN We conducted a multicenter dose-finding study in healthy, reproductive-aged women with regular cycles with sequential enrollment to increasing E2 dose groups. We evaluated serum E2 concentrations twice weekly for the primary outcome of median E2 concentrations throughout initial 30-day use (target ≥40 pg/mL). In an optional 2-cycle extension substudy, we randomized participants to 2- or 4-day ring-free intervals per 30-day cycle to evaluate bleeding and spotting based on daily diary information. RESULTS Sixty-five participants enrolled in E2 75 (n = 22), 100 (n = 21), and 200 (n = 22) mcg/day groups; 35 participated in the substudy. Median serum E2 concentrations in 75 and 100 mcg/day groups were <40 pg/mL. In the 200 mcg/day group, median E2 concentrations peaked on days 4-5 of CVR use at 194 pg/mL (range 114-312 pg/mL) and remained >40 pg/mL throughout 30 days; E2 concentrations were 37 pg/mL (range 28-62 pg/mL) on days 88-90 (n = 11). Among the E2 200 mcg/day substudy participants, all had withdrawal bleeding following ring removal. The 2-day ring-free interval group reported zero median unscheduled bleeding and two (range 0-16) and three (range 0-19) unscheduled spotting days in extension cycles 1 and 2, respectively. The 4-day ring-free interval group reported zero median unscheduled bleeding or spotting days. CONCLUSIONS Estradiol concentrations with rings releasing E2 200 mcg/day and SA 200 mcg/day avoid hypoestrogenism over 30-day use. IMPLICATIONS A 90-day contraceptive vaginal ring releasing estradiol 200 mcg/day and segesterone acetate 200 mcg/day achieves estradiol concentrations that should avoid hypoestrogenism and effectively suppresses ovulation.
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Affiliation(s)
- Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | - David K Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, United States
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - Michael A Thomas
- Reproductive Medicine Research, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, United States
| | - Bruce Variano
- Center for Biomedical Research, Population Council, New York, NY, United States
| | - Regine Sitruk-Ware
- Center for Biomedical Research, Population Council, New York, NY, United States
| | | | - Jill Long
- 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
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Micks EA, Jensen JT. A technology evaluation of Annovera: a segesterone acetate and ethinyl estradiol vaginal ring used to prevent pregnancy for up to one year. Expert Opin Drug Deliv 2020; 17:743-752. [PMID: 32410464 DOI: 10.1080/17425247.2020.1764529] [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: 10/24/2022]
Abstract
INTRODUCTION The segesterone acetate and ethinyl estradiol contraceptive vaginal ring (SA/EE CVR) was FDA-approved in August 2018 and is now available in the U.S. The CVR is placed vaginally for 21 days followed by a 7-day ring-free interval, when withdrawal bleeding typically occurs. One ring can be used for up to a year (13 cycles). AREAS COVERED This review summarizes this novel method of contraception, including the delivery system and the hormonal components. We describe the potential market, how it is used, the pharmacokinetic properties of the device, and results of clinical trials including efficacy, bleeding profile, acceptability, and safety. EXPERT OPINION The SA/EE CVR represents the first long-lasting user-controlled hormonal contraceptive device. The bleeding pattern is highly favorable and consistent over the entire year and is associated with very low discontinuation. Efficacy and safety are similar to other methods of combined hormonal contraceptives. Unscheduled ring removals increase the risk of failure. Further studies are needed to evaluate continuous use of the ring for greater than 21 days, and potential non-contraceptive benefits of the ring such as reduced menstrual bleeding.
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Affiliation(s)
- Elizabeth A Micks
- Department of Obstetrics and Gynecology, University of Washington , Seattle, WA, USA
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University , Portland, OR, USA
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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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Black A. Contraception in Canada: A Nod to the Past and Look Into the Future. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41 Suppl 2:S305-S308. [PMID: 31785681 DOI: 10.1016/j.jogc.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Amanda Black
- Department of Obstetrics and Gynecology, University of Ottawa and; The Ottawa Hospital Research Institute, Ottawa, ON.
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Black A. La contraception au Canada : Un clin d’œil au passé et un regard vers l'avenir. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41 Suppl 2:S309-S313. [DOI: 10.1016/j.jogc.2019.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Vieira CS, Fraser IS, Plagianos MG, Burke AE, Westhoff CL, Jensen J, Brache V, Bahamondes L, Merkatz R, Sitruk-Ware R, Blithe DL. Bleeding profile associated with 1-year use of the segesterone acetate/ethinyl estradiol contraceptive vaginal system: pooled analysis from Phase 3 trials. Contraception 2019; 100:438-444. [PMID: 31398307 PMCID: PMC6893119 DOI: 10.1016/j.contraception.2019.07.145] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/26/2019] [Accepted: 07/30/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe bleeding patterns among users of the segesterone acetate (SA) and ethinyl estradiol (EE) contraceptive vaginal system (CVS), and identify factors associated with unscheduled bleeding/spotting (B/S). STUDY DESIGN We pooled results from two multicenter, single-arm, open-label, pivotal, phase 3 studies of the SA/EE CVS conducted in 17 US and 7 international sites. Participants (age 18-40 years; BMI ≤29 kg/m2) followed a 21/7-day in/out schedule of CVS use for up to 13 cycles and recorded vaginal bleeding daily in paper diaries. Scheduled and unscheduled B/S were summarized by cycle. We used multiple logistic regression to identify factors associated with unscheduled bleeding/spotting, based on the first 4 cycles only. RESULTS Analysis included data from 2070 participants (16,408 cycles). Ninety-eight percent documented scheduled B/S [mean (SD): 4.9 (1.1) days/cycle)]. Absence of scheduled B/S was 5-8% of women/cycle. Unscheduled B/S ranged from 13.2% to 21.7% of women per cycle. Few women (1.8%) discontinued prematurely due to unacceptable bleeding. Black women were more likely to report unscheduled B/S than White women [Adjusted odds ratio (AOR) = 1.49, 95% confidence interval (CI) = 1.14-1.94]. Women with fewer years of schooling [ CONCLUSIONS Participants using the SA/EE CVS up to 13 cycles reported good cycle control. Discontinuation due to unacceptable bleeding was very low. Further research into demographic/other differences with reported unscheduled bleeding is warranted. IMPLICATIONS Since good cycle control is a key factor influencing contraceptive selection, adherence and continuation of combined hormonal contraceptives, the favorable bleeding profiles experienced by women during the SA/EE CVS clinical trials provide reassuring information for prospective users.
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Affiliation(s)
- Carolina Sales Vieira
- Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of São Paulo, Avenida Bandeirantes, 3900 - Campus Universitário - Monte Alegre, CEP: 14049-900, Ribeirão Preto, SP, Brazil.; Population Council, 1230 York Avenue, New York City, NY, 10065, USA..
| | - Ian S Fraser
- The University of New South Wales, School of Women's and Children's Health, Royal Hospital for Women, Barker Street, Randwick, NSW 2031, Australia
| | | | - Anne E Burke
- Department of Gynecology and Obstetrics, the Johns Hopkins University School of Medicine, Bayview Medical Center, Baltimore, MD 21224, USA
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York City, NY 10032, USA
| | - Jeffrey Jensen
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, 97239, USA
| | | | - Luis Bahamondes
- Department of Obstetrics and Gynecology, Faculty of Medical Science, University of Campinas, Caixa Postal 6181, CEP 13084-971, Campinas, SP, Brazil
| | - Ruth Merkatz
- Population Council, 1230 York Avenue, New York City, NY, 10065, USA
| | | | - Diana L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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Griffin JB, Ridgeway K, Montgomery E, Torjesen K, Clark R, Peterson J, Baggaley R, van der Straten A. Vaginal ring acceptability and related preferences among women in low- and middle-income countries: A systematic review and narrative synthesis. PLoS One 2019; 14:e0224898. [PMID: 31703094 PMCID: PMC6839883 DOI: 10.1371/journal.pone.0224898] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/23/2019] [Indexed: 11/30/2022] Open
Abstract
The vaginal ring (VR) is a female-initiated drug-delivery platform used for different indications, including HIV pre-exposure prophylaxis (PrEP). We conducted a systematic review of VR acceptability, values and preferences among women in low- and middle-income countries (LMIC) to inform further investment and/or guidance on VR use for HIV prevention. Following PRISMA guidelines, we used structured methods to search, screen, and extract data from randomized controlled trials (RCTs) and observational studies reporting quantitative outcomes of acceptability of the VR for any indication published 1/1970-2/2019 (PROSPERO: CRD42019122220). Of 1,110 records identified, 68 met inclusion criteria. Studies included women 15-50+ years from 25 LMIC for indications including HIV prevention, contraception, abnormal bleeding, and menopause. Overall VR acceptability was high (71-98% across RCTs; 62-100% across observational studies), with 80-100% continuation rates in RCTs and favorable ease of insertion (greater than 85%) and removal 89-99%). Users reported concerns about the VR getting lost in the body (8-43%), although actual expulsions and adverse events were generally infrequent. Most women disclosed use to partners, with some worrying about partner anger/violence. The VR was not felt during intercourse by 70-92% of users and 48-97% of partners. Acceptability improved over time both within studies (as women gained VR experience and worries diminished), and over chronological time (as the device was popularized). Women expressed preferences for accessible, long-acting, partner-approved methods that prevent both HIV and pregnancy, can be used without partner knowledge, and have no impact on sex and few side effects. This review was limited by a lack of standardization of acceptability measures and study heterogeneity. This systematic review suggests that most LMIC women users have a positive view of the VR that increases with familiarity of use; and, that many would consider the VR an acceptable future delivery device for HIV prevention or other indications.
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Affiliation(s)
- Jennifer B. Griffin
- RTI International, Center for Global Health, Durham, NC, United States of America
| | - Kathleen Ridgeway
- FHI 360, Global Health Population and Nutrition, Durham, NC, United States of America
| | - Elizabeth Montgomery
- RTI International, Center for Global Health, Durham, NC, United States of America
| | - Kristine Torjesen
- FHI 360, Global Health Population and Nutrition, Durham, NC, United States of America
| | - Rachel Clark
- RTI International, Public Health Research Division, Durham, NC, United States of America
| | - Jill Peterson
- FHI 360, Global Health Population and Nutrition, Durham, NC, United States of America
| | | | - Ariane van der Straten
- RTI International, Center for Global Health, Durham, NC, United States of America
- University of California, San Francisco, Department of Medicine, San Francisco, CA, United States of America
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Bongaarts J, Sitruk-Ware R. Climate change and contraception. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:233-235. [PMID: 31615904 DOI: 10.1136/bmjsrh-2019-200399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 06/10/2023]
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Nelson AL. Comprehensive overview of the recently FDA-approved contraceptive vaginal ring releasing segesterone acetate and ethinylestradiol: A new year-long, patient controlled, reversible birth control method. Expert Rev Clin Pharmacol 2019; 12:953-963. [DOI: 10.1080/17512433.2019.1669448] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Anita L. Nelson
- Obstetrics & Gynecology, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA
- Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Obstetrics & Gynecology, University Southern California, Los Angeles, CA, USA
- Research Division, Essential Access Health, Los Angeles, CA, USA
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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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