An open-label noncomparative study to evaluate the vagina and cervix of NuvaRing® users

The effect of different contraceptive methods on the vaginal microbiome

Introduction: Following a historical overview, the effect of different contraceptive methods on vaginal microbiome has been reviewed and summarized.Areas covered: Effects of combined hormonal contraceptives (oral or vaginal) and of progestin only (injectable and implantable), intrauterine devices/systems (copper- or levonorgestrel-releasing), on vaginal microbiome. In addition, mention is made of vaginal rings releasing antiviral drugs and lactic acid.Expert opinion: The vaginal microbiota (VM) is unique in that it is normally dominated by Lactobacillus species providing a degree of protection against infections; this however may vary, depending on the species and strains of Lactobacillus. Bacterial Vaginosis represents the most common dysbiosis of the VM and its prevalence can be influenced by use of contraception. Available evidence indicates that, under the influence of oral or systemically administered female sex hormones, there is apromotion of vaginal eubiosis, with aprevalence of ahealthy VM in which Lactobacilli predominate.

"Per vaginam" topical use of hormonal drugs in women with symptomatic deep endometriosis: a narrative literature review

PURPOSE

We aim to provide a comprehensive overview of the role of the vagina as a route for drug delivery and absorption, with a particular focus on the use of vaginal hormonal compounds for the treatment of deep infiltrating symptomatic endometriosis.

METHODS

A MEDLINE search through PubMed was performed to identify all published studies in English language on vaginal hormonal treatments for symptomatic endometriosis.

RESULTS

Main advantages of the vaginal route include avoidance of the hepatic-first pass metabolic effect, the possibility of using lower therapeutic dosages, and the reduction of side effects compared with the oral administration. Studies on endometriosis treatment mainly focused on the use of vaginal danazol (n = 6) and the contraceptive vaginal ring (n = 2). One pilot study evaluated the efficacy of vaginal anastrozole in women with rectovaginal endometriosis. Most investigations evaluated the vaginal use of hormonal agents in women with deep infiltrating endometriosis/rectovaginal endometriosis. Overall, a substantial amelioration of pelvic pain symptoms associated with endometriosis was observed, particularly of dysmenorrhea. A significant reduction in rectovaginal endometriotic nodule dimensions measured at ultrasound examination was detected by some but not all authors.

CONCLUSIONS

The vaginal route represents a scarcely explored modality for drug administration. High local hormonal concentrations might achieve a greater effect on endometriotic lesions compared with alternative routes. Future studies should focus on the use of the vagina for delivering target therapies particularly in patients with deeply infiltrating rectovaginal lesions.

Vaginal health in contraceptive vaginal ring users - A review

BACKGROUND

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

METHODS

A systematic review of the literature.

RESULTS

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

CONCLUSION

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

Evaluation of menstrual bleeding patterns: a new proposal for a universal guideline based on the analysis of more than 4500 bleeding diaries

OBJECTIVE

To develop a universal guideline allowing the comparison of interventions like oral contraceptives and hormone replacement therapy with an impact on menstrual bleeding pattern.

METHODS

Literature analysis and cluster analysis of 4612 bleeding diaries.

RESULTS

We summarized key definitions needed for the evaluation of menstrual bleeding patterns from the literature. We developed a methodology to systematically evaluate menstrual bleeding patterns that distinguishes between cyclical and continuous hormonal regimens.

CONCLUSION

This universal guideline can be applied to all prospective clinical studies that affect menstrual bleeding patterns. It allows regulatory agencies and prescribing physicians to make meaningful comparisons of different products.

Contraceptive vaginal ring

The vaginal contraceptive ring is comprised of ethinyl vinyl acetate that releases ethinyl estradiol and the third-generation progestin, etonorgestrel. It was approved by the Food and Drug Administration in 2001. The vaginal contraceptive ring is highly efficacious with a Pearl Index of 1.18 and an efficacy of 99.1%. Effectiveness is similar with actual use.

A Comparison Between the Vaginal Ring and Oral Contraceptives

OBJECTIVE

To investigate whether contraceptive vaginal ring use results in similar estimated genital symptoms, signs, examination, and laboratory findings compared with oral contraceptive use.

METHODS

Women were randomly assigned to either contraceptive vaginal ring or a 20 microg ethinyl estradiol oral contraceptive pill use for 3 consecutive 28-day cycles, directly followed by 3 cycles of the study drug not initially assigned. Subjects scored genital symptoms on a daily diary using a 0-4 scale and underwent a baseline, cycle 2, cycle 4, and exit pelvic examination including vaginal discharge evaluation, vaginal Gram stain and white cell count, and culture for yeast and Lactobacillus, including colony count and hydrogen peroxide production.

RESULTS

Of the 40 subjects assigned to each arm, 33 (82.5%) subjects in the ring-first arm and 31 (77.5%) subjects in the pill-first arm completed all study visits (P =.58). Most subjects reported few genital symptoms with either method, but 63% of subjects reported vaginal wetness during ring use compared with 43% during pill use. During ring use larger numbers of Lactobacillus colonies present were positive for hydrogen peroxide production (fold difference 2.67, 95% confidence interval 1.49, 4.78, P <.001). All other laboratory data, including yeast colony counts, Nugent Gram stain score, vaginal white blood cell count, vaginal pH, and discharge weight, were not significantly different by method.

CONCLUSION

Some women may notice an increase in vaginal wetness during contraceptive ring use yet the method is well tolerated and appears to improve the vaginal flora.