Tampon use may indicate vaginal ring acceptance

As a clinician who counsels on contraceptive choice, how can you determine if a woman is a likely candidate for the contraceptive vaginal ring (NuvaRing, Merck & Co., Whitehouse Station, NJ)? New research suggests that young women who report tampon use are more likely to choose the contraceptive vaginal ring over oral contraceptives as their initial birth control method.1

The study was conducted as part of the Contraceptive Choice Project, a longitudinal study of 10,000 St. Louis area women. The project is designed to promote the use of long-acting, reversible methods of contraception while evaluating user continuation and satisfaction for all reversible methods.

To perform the current study, researchers performed univariable and multivariable analyses of the 311 women who were asked about tampon use at the time of enrollment in the project and who chose the contraceptive vaginal ring or combined oral contraceptives (COCs) in an effort to assess the association of tampon use and choice of combined hormonal method. Adjusted analysis indicated that tampon users were more likely to choose the contraceptive vaginal ring instead of combined pills (adjusted relative risk 1.34, 95% confidence interval 1.01-1.78).

While use of tampons might be considered an indicator for the initial acceptability of the contraceptive vaginal ring, all women should be offered the contraceptive vaginal ring regardless of experience with tampon use, says study co-author Renee Mestad, MD, clinical fellow at the Washington University School of Medicine, St. Louis.

"Many women enjoy the benefits of COCs, but have difficulty remembering to take the pill daily and subsequently quit using them without letting their clinician know," Mestad says. "When patients know there are other similar, but more user-friendly options available, they may be more inclined to call their clinician to try something else."

Don't think that women who do not use tampons aren't interested in the vaginal ring as well; in the current study, 7% overall of such women chose the ring when all options were presented, says Mestad. Tampon users have an easier time imagining or "visualizing" in a sentient way how to place the ring and how it would feel once placed, she says.

"Clinicians would only need to take an extra few minutes to explain to non-tampon users that the ring is not felt by the patient when it sits properly in the vagina," Mestad says. "Clinicians can also offer to place the first ring for their interested but skeptical patients to demonstrate the ease of placement and how it should feel when in place."

Who picks the ring?

Melissa Gilliam, MD, MPH, associate professor of obstetrics and gynecology at the University of Chicago and chief of its Division of Family Planning and Contraceptive Research, is looking at factors surrounding young women's selection of the contraceptive vaginal ring. Her research team is conducting the ACCEPT (Acceptability of NuvaRing versus Birth Control Pills in College Women) study to look at these factors.

In an early study, researchers surveyed college students regarding reasons for selecting the ring versus other methods,2 says Gilliam. Those women who were interested in using the ring liked the fact that it was non-daily, did not mind self-insertion, did not mind feeling the ring during intercourse, liked the idea of a monthly method, had busy schedules, and were concerned about side effects, Gilliam reports. Women who were using oral contraceptives were less likely to consider using the ring.2

Gilliam's research team has just published results of a study designed to compare satisfaction with and adherence to the contraceptive vaginal ring and a daily low-dose oral contraceptive pill among college and graduate students.3 To conduct the study, researchers randomly assigned 273 women to the contraceptive vaginal ring (n = 136) or pill (n = 137) for three consecutive menstrual cycles. Participants completed daily Internet-based, online diaries regarding method adherence and satisfaction during cycles of use. At three months, they completed an online survey regarding intention to continue their method and overall acceptability. At six months, scientists surveyed participants to see whether they continued using contraception and, if so, which method was used.

"We found that many women did not continue their method — ring or pill — due to the cost of the method," observes Gilliam. "Discontinuation reasons specific to the ring included concerns about side effects, such as discharge or bleeding, and some were not sexually active, so discontinued the method. But most liked the method."


  1. Tepe M, Mestad R, Secura G, et al. Association between tampon use and choosing the contraceptive vaginal ring. Obstet Gynecol2010; 115:735-739.
  2. Gilliam ML, Holmquist S, Berlin A. Factors associated with willingness to use the contraceptive vaginal ring. Contraception 2007; 76:30-34.
  3. Gilliam ML, Neustadt A, Kozloski M, et al. Adherence and acceptability of the contraceptive ring compared with the pill among students: a randomized controlled trial. Obstet Gynecol2010; 115:503-510.