Dear readers, I am very pleased with your active interest! You ask questions that I haven’t asked myself, allow me to look at the problem from a different angle, contribute to the realization of several of my highest needs according to Abraham Maslow, stimulate interest in mastering new and clarifying known information, and give impetus to growth and development! Thank you! Let's continue to grow and develop together. They say correctly, one mind is good, but... the more, the better!
I was very pleased by the request to share knowledge about the well-known vaginal hormonal ring. At first, the request surprised me very much, since the ring is very similar in its mechanism of action, indications and contraindications to combined oral contraceptives (COCs) (therefore, the corresponding analogy will be given very often in the text). And then I got carried away with searching for differences: as it turned out, in addition to the route of administration, there were several more. Dear reader, who asked the question, the birth of this article is entirely your merit!
In order to save your time, at the end I have given the quintessence of what was written. So, if you don’t have time for lyrics and explanations, you are welcome to scroll down the main text. And, dear readers, I ask for feedback on the summary at the end, will this format of my future publications be pleasant to read?
Also, during the course of the main text, I decided to ask you questions, and I will be very glad to see your answers!
Question 1: Do you use hormonal contraception? If the answer is yes, then what is her option? And are you satisfied?
Hormone ring on the agenda
This publication, despite my generally positive opinion about the drug, is in no way an advertisement. I’ll honestly tell you about the positive and negative sides of this option for protecting against unwanted pregnancy.
The vaginal hormonally active ring refers to combined hormonal contraceptives, with an alternative option for the supply of hormones to COCs. The drug is a flexible ring with a diameter of 54 mm, consisting of a hypoallergenic material (ethynyl vinyl acetate) used for the manufacture of implants.
The contraceptive, like COCs, contains two active components: estrogenic (ethinyl estradiol) and gestagenic (etonogestrel).
The drug has no analogues in our country. More than one and a half million women around the world use this particular contraceptive option, and the world experience of use spans 18 years.
Why are they looking for an alternative to birth control pills?
The search for alternative options for the use of combined contraception is due to the fact that not every woman is satisfied with daily oral administration of the drug.
- Not everyone is so disciplined that they have never missed a pill, at least among my patients - only a few are able to take the drug at the same time.
- Moreover, the passage of the drug through the stomach and primarily through the hepatic circulation, whatever one may say, is an additional burden on the above organs.
- And the most justified reason for searching for a non-tablet method of introducing the drug into the body: the search for the minimum effective dose of active ingredients. I know of only one oral drug that is equivalent in dose to the vaginal ring of ethinyl estradiol. The lower the hormonal load and systemic exposure, the safer the drug profile.
Mechanism of action of the vaginal ring
- The basis is the suppression of ovulation by maintaining a constant concentration of sex steroids in the peripheral blood and reducing the production of gonadotropic hormones (without their participation, ovulation becomes impossible).
- The second mechanism is the thickening of the mucus located in the cervical canal of the cervix, which makes it difficult for sperm to move into the uterine cavity and fallopian tubes.
- In addition, changes occur in the endometrium (the mucous membrane of the uterus), leading to the impossibility of implantation (introduction) of the fertilized egg and the development of pregnancy.
- The motor activity of the fallopian tubes also changes, which slows down the movement of sperm.
What is the reason for the creation of a vaginal hormonal ring?
The choice of the vaginal route of drug administration is determined by the anatomical and functional features of the vagina.
The vagina is anatomically a hollow connective tissue-muscular tube, truncated in the upper third, 10-12 cm long, covered with a folded mucous membrane, which provides good extensibility of the walls and significant capacity of the organ. Just imagine, physiologically it is created to carry out one of the most important functions of a woman - reproduction! During vaginal delivery, the vagina stretches to the size of the head of a full-term fetus: diameter 9.5 cm, circumference 32 cm! Do you think a woman will feel a ring with a diameter of 54 mm?
It is also known that the temperature and tactile sensitivity of the vagina in the upper two-thirds is reduced, and the upper third of the vagina is located horizontally. This indicates that the ring will not fall out and will not be felt by the woman (although anything can happen in life!).
The ring is also held in place by the muscles of the urogenital and pelvic diaphragms and the physiologically closed vaginal walls. The vaginal mucosa is well supplied with blood, which creates favorable conditions for the absorption of active substances into the systemic circulation.
How to install a vaginal ring?
The ring is elastic and for insertion into the vagina it is enough to squeeze it in the anteroposterior direction between the thumb and forefinger and insert it vaginally like a regular tampon.
Next, use your index finger to push the ring into the upper third of the vagina or to a comfortable position.
Next, the contraceptive will independently take the required position in the vagina, more often around the cervix, this fact was confirmed by the manufacturer based on the results of MRI studies of the subjects.
Details of the position of the ring will not affect the contraceptive effect, as long as it remains in the vagina.
Typically, patients do not have any difficulties with inserting and removing the ring. But it happens that the first time the master class is conducted at an appointment by a gynecologist, then women successfully use the method on their own.
Reviews from gynecologists
The Nuvaring ring receives extremely positive reviews from experts. This is probably why this contraceptive is so often prescribed to women. So, what exactly information is contained in the reviews of gynecologists about the Nuvaring ring? The following are especially highlighted:
- A convenient means of contraception for those who cannot use others (hormonal IUD or oral contraceptives) and do not want or cannot use barrier methods of contraception.
- It is recommended to use it for some time for those women who are trying to get pregnant (shows good results in fertilization on the withdrawal effect).
Unfortunately, it is extremely rare today to select contraceptives based on the results of hormone tests. That is why the Nuvaring ring (reviews confirm this fact), even if it is used as prescribed by a doctor, is not suitable for every woman. Therefore, consumer feedback may provide a clearer and more truthful picture than physician opinions. We will consider them further.
How effective is the hormonal ring?
The content of hormones in each ring is designed to guarantee stable maintenance of the required concentrations of active substances in the systemic circulation for the implementation of a contraceptive effect.
The maximum is reached during the first week of use, decreasing slightly by the end of the third week.
15 mcg of ethinyl estradiol and 120 mcg of etonogestrel are released daily, which is less than most COCs.
Moreover, the effectiveness of this method of contraception is comparable to that when using COCs.
The ring must remain in the vagina for three weeks, after which it must be removed, which is not difficult at all.
Next, you need to take a seven-day break, and then reintroduce a new contraceptive.
If you need to delay the onset of a menstrual-like reaction, you, as when using COCs, can do this by inserting a new ring immediately after removing the contraceptive. Naturally, the duration of its presence in the vagina should also be three weeks.
Is it possible to “push back your period” using a contraceptive?
Many women sooner or later become interested in how to delay their periods with Nuvaring before a wedding, a trip to the sea, or other important event. If you do not want to increase the chances of an unplanned pregnancy, we do not recommend installing the ring for longer than 3 weeks. If you want to “push back your period” after the end of the three-week period, you need to replace the old hormonal ring with a new one and, at the end of the new three weeks, remove the ring and wait for the arrival of your period.
To delay your period, you do not need to take a 7-day break. This induced period delay will allow you to delay your period by three weeks, although the chance of spotting increases.
When a vaginal ring causes discomfort
There are situations when a woman feels the ring and its use causes discomfort, which is a reason to refuse the drug.
This happens infrequently, mainly among those who, for the same reasons, do not use tampons. As a doctor, I don’t feel much love for this personal hygiene product due to the fact that discharge from the uterine cavity accumulates in the vagina, which physiologically should leave the body (and in nature nothing is created “just like that”, everything is carefully thought out).
But in the conditions of our life, the occasional use of tampons is a necessity, which is justified in situations where you need to be “on top”.
So, how you feel when using tampons can serve as a predictor of acceptability for the vaginal option of combined contraception.
When to consult a doctor
Using Nuvaring, you should consult a doctor in the following cases:
- if menstruation has not started 1 month after the delay at the initial stage of using the ring;
- if you notice side effects from the installed ring and possible allergy symptoms;
- with too noticeable mood swings;
- if heavy periods last more than 5-7 days, although previously they were always scanty or normal;
- if the brown spotting does not stop in the middle of the cycle 3 months after the first ring is installed.
Can a vaginal ring fall out?
Often ring users, especially in the first months of use, worry about the location of their contraceptive: has it fallen out?
Frankly speaking, this is rare, but it does happen. The manufacturer in the instructions for the drug recommends regularly checking the location of the ring. Checks are especially relevant after sexual intercourse or going to the toilet, as well as if a tampon was suddenly used (although this is unlikely, the drug extremely rarely gives a side effect in the form of spotting) or, perhaps, douching was performed (do not do this, Please!).
None of my patients had such an incident. But, if it does happen, the main task is to return it to its place as soon as possible by rinsing it with cold or warm (but not hot!) water.
There is no need to sterilize the ring. The vagina is not sterile.
Vaginal ring: contraindications
Before using a vaginal ring, you should consult a gynecologist. The contraceptive is not recommended for women suffering from migraines, obesity, arterial hypertension, thrombophlebitis, diabetes mellitus, pancreatitis. Also among the contraindications to this contraceptive are: heart defects, family cases of thrombosis, severe liver diseases, tumors of the reproductive system, breast, and liver. It is not advisable to use a vaginal ring for smoking women who have crossed the 35-year mark, as well as for those who suffer from severe chronic constipation.
Does a vaginal hormonal active ring cause bacterial vaginosis?
There is an opinion that the use of vaginal contraception contributes to the development of bacterial vaginosis, which has not been confirmed in studies.
In 63% of cases, women using a hormonal ring note increased moisture in the mucous membrane and increased secretion (more vaginal discharge). This fact can be explained both by the local effect of hormonal influences and by the presence of a foreign body in the vagina. For reference, 43% of women who use COCs also report increased vaginal moisture. In their practice, obstetrician-gynecologists often use pessaries, which is also associated with an increase in vaginal secretion.
Analysis of the discharge showed the absence of inflammatory and dysbiotic changes.
On the contrary, vaginal ring users, compared to patients using COCs, had a 2.7 times higher number of lactobacilli producing hydrogen peroxide, a natural protective factor that suppresses the growth of conditional pathogens and protects against absolute ones.
In addition, one of the mechanisms of action of the vaginal ring is the thickening of cervical mucus, which also provides infection protection.
Overdose
What happens if you use the Nuvaring ring incorrectly? The consequences (reviews describe them in all colors) can be the most unpleasant. As a rule, they occur when artificially high dosages of the drug in question are used. What could be the symptoms in this case? Bloody discharge from the vagina, nausea and vomiting are possible. As experts say about the contraceptive ring “Novaring”, there is no one specific antidote that would relieve all unpleasant symptoms at once. Treatment will be prescribed exclusively symptomatic. If you notice the appearance of at least one of the conditions listed above, it is important to immediately contact your doctor, who will prescribe therapy and also be able to figure out whether you should continue to use the contraceptive in question.
Change in libido when using a vaginal ring
In terms of libido, most women who use the ring note an increase in sexual desire and increased sexual satisfaction.
It is interesting to note that the presence of such an extraordinary thing as a ring in the vagina stimulates sexual interest on the part of not only the woman, but also the opposite sex. A number of couples surveyed draw an analogy between a ring and a sex toy, which cannot but affect the fantasies that precede sexual intercourse.
However, there is also the exact opposite point of view. One thing I can say for sure is that no one remains indifferent, and interest, whatever it may be, is interest.
Side effects
According to patient reviews of the Nuvaring ring, side effects may occur with some frequency. A number of women do not feel them at all, while others suffer from them throughout the entire time they use the drug. How to determine which group you belong to? Consultation with a qualified medical practitioner should be sought. So, what are the side effects of the Nuvaring ring from expert reviews? The most commonly reported reactions are:
- Increased fatigue, weakness.
- Dizziness.
- Headache.
- Depressed, depressed state.
- Unreasonable anxiety.
- Emotional lability.
- Migraine-like headache or migraine itself.
- Cystitis.
- Vaginitis.
- Increase in body weight.
- Nausea.
- Decreased libido.
- Vomit.
- Quincke's edema.
- Difficulties during sexual intercourse that are directly related to the placement of the ring.
- Abnormal stool.
- Hives.
- Dysmenorrhea.
- Cervicitis.
- Skin itching.
- Pain in the epigastric region.
- Vaginal discharge.
- Enlargement and sensitivity of the mammary glands.
It is important to remember: in order not to experience side effects and not to become pregnant, reviews of gynecologists strongly recommend using the Nuvaring ring only as prescribed by a doctor and exclusively according to the instructions. If you do experience one of the conditions listed above, immediately contact a specialist who can adjust the use of contraception.
Does a vaginal ring bother men?
It would be more correct to ask the stronger half of humanity about the sensations that a man experiences when using this method.
Publications about the drug describe increased sensations or no changes.
The instructions for the drug describe cases of local reactions in the partner, including irritation, abrasions, and discomfort.
Similar situations occur in life, although most patients and their partners are satisfied with the method.
In addition, the manufacturer writes in the instructions about the possibility of removing the contraceptive “with impunity” (in terms of reducing the contraceptive effect) for a period of up to three hours. Therefore, sexual intercourse may well occur without a ring, if suddenly it interferes.
The effect of Nuvaring on menstruation
The ring is aimed at changing a woman's monthly cycle. During a normal and natural cycle, the female body is involved in daily hormonal changes throughout the entire month. In the absence of pregnancy, menstruation begins and after its end the process begins anew. If the Nuvaring ring is installed, the active components suppress the production of those hormones that are responsible for the formation of the egg, so periods when using Nuvaring become fully regulated.
If your period starts in a few days, it’s time to buy your first Nuvaring ring. It is installed on days 1-2 of the cycle and during the first 22 days the ring increases progesterone levels and suppresses estrogen levels in the female body. After the ring is removed, progesterone levels drop and artificial menstruation occurs.
Most often, after installing the ring, a woman expects two scenarios of events - the first menstruation with Nuvaring does not occur or lasts for a very long time. Such failures and adjustments can last up to 3 months of using the ring and are considered completely normal.
Pleasant effects for women
- The improvement in the woman’s sensations can be explained by a number of factors: confidence in protection from unwanted pregnancy, lack of thinking about whether she forgot to take the pill, good hydration of the vaginal mucosa, and awareness that the man’s sensations should supposedly be brighter. Again, everything is individual. Rarely, but patients complain, on the contrary, of vaginal dryness, lack of lubrication during sexual intercourse and lack of desire.
- A pleasant effect of a vaginal contraceptive is better control of the menstrual cycle compared to COCs. That is, a menstrual-like reaction occurs during a seven-day break and lasts from 2 to 4–5 days, which is not always possible to achieve when using microdosed COCs. The frequency of such undesirable effects as “breakthrough bleeding” (a situation when, when using a contraceptive, a menstrual-like reaction occurred regularly, and then acyclic heavy or moderate bleeding suddenly appeared) and acyclic spotting when using a vaginal ring is significantly lower.
- Despite the existence of isolated publications about the high risk of thrombosis when using combined vaginal contraception, the vast majority of reports, common sense and the regulatory framework allow us to make an unambiguous conclusion that the risk of thrombosis is comparable, or rather lower, than when using COCs, since the dose of ethinyl estradiol here is minimal.
Restoring the monthly cycle after stopping Nuvaring
According to statistics, women with an irregular natural menstrual cycle experience brown discharge after 4-6 months. Some women experience oligomenorrhea, when menstruation occurs less than once every 40 days. In more rare cases, heavy periods are possible. Most often, 4-6 months is enough to restore a healthy normal cycle after removal of the Nuvaring vaginal ring.
How does the drug affect weight?
Like most modern COCs. The drug has no weight loss effects. But it will not increase if you monitor your eating behavior.
In theory, the gestagen of the drug has a residual androgenic effect, which means it can influence carbohydrate and lipid metabolism, but no significant changes were found in clinical studies.
When surveyed, information about the patient’s side effects, as with the use of any COCs (even those that promote weight loss), indicated that it was the drug that was to blame for the increase in the hated numerical value.
Dear girls and women! Remember that as the time interval increases relative to the four digits indicated in the passport, the weight also increases. Unfortunately, this is physiology. There are happy owners of magical heredity who are, rather, the exception to the rule. And the rest have to work on themselves and limit themselves in the pleasure of eating delicious food. However, we have already discussed this issue in the article “Wrong reasons for refusing hormonal contraception.”
Pregnancy
It is important to remember that the Nuvaring ring instructions and reviews from gynecologists categorically prohibit women from using it not only during pregnancy, but also if there is a suspicion of pregnancy. Before you start using a new ring (which, by the way, needs to be changed every month), it is important to exclude pregnancy through examination by a qualified specialist if there was a risk of becoming pregnant in the previous month (cycle) (for example, unprotected sexual intercourse). Also, reviews from doctors prohibit the use of the Nuvaring ring while a woman is breastfeeding her baby. It is possible to resume its use only after the mother stops breastfeeding, so that the use of contraception does not affect the child in any way.
Should I use a vaginal ring?
In my opinion, as a doctor, the method is worthy, but it is not suitable for patients with certain gynecological diseases.
The presence of only one combination of estrogen and gestagen components does not allow this option to be flexible enough and, if when using COCs it is possible to change the active ingredients, being in fact within the framework of one method, then here - alas and ah!
It has only one indication: contraception! And since healthy girls are at the appointment “with fire during the day...”, I personally don’t have to prescribe it very often. And yet, the non-contraceptive effect, although not specified in the instructions, is present thanks to the etonogestrel included in the composition: good cycle control.
Reasons for decreased effectiveness of the vaginal ring
The effectiveness of the vaginal ring may be reduced if the following medications are used simultaneously:
- anticonvulsants (phenytoin, barbiturates, carbamazepine, primidone, topiramate, oxcarbazepine, lamotrigine);
- antifungal (griseofulvin);
- drugs used to treat HIV infection (ritonavir);
- products containing St. John's wort;
- some antibacterial drugs (ampicillin, rifampicin, tetracycline antibiotics).
At the same time, if there is a need to take antibacterial drugs, the manufacturer of the vaginal contraceptive has provided two antibiotics that can be taken together with the drug safely and without fear: amoxicillin and doxycycline (the latter is from the tetracycline group). Their intake affects the metabolism of steroids to a small extent, which has been proven in clinical studies.
Is it expensive to use a hormone ring?
An important aspect of the patient’s adherence to a particular method of contraception is the cost of the issue. Of course, they don’t skimp on health, but not everyone has such an opportunity. Therefore, before prescribing this or that drug, I try to bring the economic component to the patient.
The cost of one ring at the time of writing ranges from 1060.10 to 1699.00 rubles. If, usually, by buying a COC for three months at once, you can save a lot of money, but here, unfortunately, this principle does not work: the minimum cost of three rings is 3,108.60 rubles.
For comparison, COCs with a similar composition can be purchased for 350 rubles and more. But there are also drugs similar in price to the ring, with a different composition of active ingredients.
In any case, there are a lot of options in the COC group, including a large number of generics (drugs with identical composition, but produced by another manufacturer), which allows you to choose a contraceptive for every taste and budget, in the case, of course, there are no contraindications.
