Extending the use of vaginal ring eyed

[Editor's note: This story discussed off-label use of the vaginal ring (NuvaRing, Schering-Plough Corp.; Kenilworth, NJ).]

Many clinicians are familiar with continuous use of oral contraceptives, but how about extended regimen use of the vaginal ring? The advantages of extended cycling of the ring parallel those of extended-cycle use of the Pill, says Anne Burke, MD, MPH, assistant professor in the Department of Gynecology and Obstetrics at the Johns Hopkins University School of Medicine. Burke presented information on the vaginal ring and other established methods of birth control at the recent Contraceptive Technology Quest for Excellence Conference.1

By extending use of the ring, women gain control over the timing of their own periods and experience reduced blood loss due to fewer and lighter periods, observes Burke. Extended cycle use also offers control of pre- and peri-menstrual symptoms that might be hormonally related, such as premenstrual syndrome and menstrual headaches, she notes.

While the ring has been found to be effective and tolerable when used without a hormone-free interval, breakthrough bleeding or spotting is a frequent side effect of extended-cycle hormonal contraception. In a 2005 study, 43% of women on a 49-day ring cycle experienced breakthrough bleeding, compared with 16% of those on a 28-day cycle.2

The main disadvantage of extended use of the ring lies in the potential for irregular or breakthrough bleeding as a side effect, notes Burke. "This can be troublesome or annoying to some women," she notes. "It is usually not heavy and seems to improve with time."

Extended-regimen use of the vaginal ring is currently considered "off label," but scientific evidence is emerging on its effectiveness. A 2009 study looked at the bleeding patterns of women using extended regimens of the vaginal ring compared to oral contraceptives.3 Both groups used their respective contraceptive method over continuous periods of 84 days, followed by a seven-day pause, over one year. The total number of scheduled bleeding and spotting days decreased significantly during the one-year period of the study for both methods (p = 0.001; the decrease was significantly higher for Pill users. Scientists note there was a significant reduction in the total number of unscheduled bleeding and spotting days for both methods (p = 0.01), but the decrease was significantly higher among vaginal ring users (p = 0.003).3

A 2008 study did an assessment of bleeding patterns with continuous use of the ring.4 Scientists designed a prospective analysis of daily menstrual flow during a 21/7 cycle, followed by six months of continuous use and institution of a randomized protocol to manage breakthrough bleeding/spotting. Women who completed the baseline 21/7 phase were randomized equally into two groups during the continuous phase. One group was instructed to replace the ring monthly on the same calendar day with no ring-free days. The second group was instructed to use the same process, but if breakthrough bleeding/spotting occurred for five days or more, they were to remove the ring for four days, store it, and then reinsert that ring. Most patients had no or minimal bleeding during continuous use, with the second group experiencing a statistically greater percentage of days without breakthrough bleeding or spotting (95%) compared with Group 1 (89%) (P = 0.016).4

This four-day "taking a break" described in the 2008 study might help women who choose to use the ring on a extended basis deal with breakthrough bleeding and continue with the method, says Burke. "For some women, the breakthrough bleeding may make them not want to do extended ring cycling, while for others, some spotting here and there is a small price to pay for the benefits they may get," she says. "There is no 'buildup' of hormones with extended ring use, as the contraceptive hormone levels decrease pretty quickly upon ring removal."

How can women use the vaginal ring in an extended regimen? For some women, the memory-triggering mechanism of the calendar day switch (changing the ring on the same date each month) might work, says Burke. For others, replacing the ring every 28 days might be acceptable, depending on patient preference.5


  1. Burke A. What's new with the older methods? Rings, patches, Depo and more. Presented at the 2009 Contraceptive Technology Quest for Excellence conference. Atlanta; October 2009.
  2. Miller L, Verhoeven C, Hout J. Extended regimens of the contraceptive vaginal ring: A randomized trial. Obstet Gynecol 2005; 106:473-482.
  3. Guazzelli CA, Barreiros FA, Barbosa R, et al. Extended regimens of the vaginal contraceptive ring: Cycle control. Contraception 2009; 80:430-435.
  4. Sulak PJ, Smith V, Coffee A, et al. Frequency and management of breakthrough bleeding with continuous use of the transvaginal contraceptive ring: A randomized controlled trial. Obstet Gynecol 2008; 112:563-571.
  5. Rowland K, Schumann SA. When to suggest this OC alternative. J Fam Pract 2009; 58:207-210.