Vaginal Rings: The Future is Now
Guest contributors are Saumya RamaRao, senior associate, and Loreley Villamide-Herrera, biomedical program manager, at the Population Council.
Expanding contraceptive options for voluntary family planning is critical for three reasons. First, different individuals have different needs for pregnancy protection depending on their own individual and family situations. Further, a woman’s needs may change as she progresses through her reproductive life. With that in mind, family planning programs that focus on high-quality services and human rights should offer a wide range of contraceptive options to meet her needs, wherever she’s at in life.
Second, we know that some women discontinue use of contraceptives, even if they still don’t intend to become pregnant. In developing countries, discontinuers constitute nearly two-fifths of women (38%) who report they do not want a pregnancy at that time but are not using contraception. Having a wider choice of contraceptives available will help meet the needs of some discontinuers if they have the option of switching to an alternate method more in line with their own preferences and needs. Empirical evidence from 19 low- and middle-income countries provides support to this idea — research shows that when just one additional method is available to women in a given location, contraceptive prevalence increases by 8 percentage points. Supporting women’s desire to switch methods from one to another also helps uphold their reproductive rights.
Third, the other three-fifths of women (62%) with an unmet need for family planning have never used contraception before. A wider range of contraceptive options may appeal to some of these potential users, especially if they have negative preconceptions about specific contraceptives or if they are seeking a method which is new and has attractive features.
For these reasons, expanding the range of contraceptive options is important—it helps individuals make choices appropriate to their needs and circumstances, allows them to switch from one method to another, and reflects a focus on quality and rights.
What are vaginal rings?
Vaginal rings are a novel drug delivery platform unlike other forms of existing contraceptives.
They are unique from pills, injections, implants, IUDs, and barrier methods (e.g. condoms). They are “mid-acting” products that are not episodic (used at the moment of intercourse, like condoms), do not require daily action (like pills) or require clinical services for placement or removal (like IUDs or implants). Furthermore, because the ring is placed in the vagina, smaller doses of hormones are needed to achieve the same level of protection as other forms of contraception.
Benefits to women and to health systems
Vaginal rings also offer important benefits to women who use them and to health systems in complementary ways. Rings are a product under a woman’s own control, offering independence from health care providers and sexual partners. Because the ring is a self-use product, it can be inserted and removed at will once the user has been counseled about the product and learns how to use it. Women are not reliant on health care providers to begin to use the product or discontinue it.
Health systems – particularly in low-resource settings – would also benefit from vaginal rings, which can be provided by all cadres of family planning providers from OB/Gyns to front-line workers, like midwives and even community-based health workers. There is minimal requirement in terms of clinical training or specialized equipment and supplies (as opposed to IUDs or implants), and because most rings do not need refrigerated storage, they can be easily integrated into existing health systems.
Since rings can be provided by a range of providers, there is potential for both public and private sector providers to be engaged in service delivery. Private commercial sector providers, such as pharmacies and lower level drug stores, may find rings attractive given the potential of adding a new product line in their locations and attracting customers. A diverse range of providers and outlets will enhance access points for consumers.
Vaginal rings for different uses
On the market today, vaginal rings are available for two primary purposes—for contraception and hormonal therapy. Progering® is a 3-month contraceptive ring containing natural progesterone and was designed exclusively for use by breastfeeding women in the first year after giving birth. NuvaRing® is a monthly ring which contains two hormones – etonogestrel and ethinyl estradiol – and is intended for women who wish contraceptive protection but are not currently breastfeeding. Vaginal rings providing hormonal therapy include Fertiring®, Estring® and Femring®.
What’s new and coming down the pike?
In the coming years, we hope to see growth in the number of vaginal rings on the market. For example, the segesterone acetate/ethinyl estradiol vaginal ring developed by the Population Council is currently under review by the U.S. Food and Drug Administration (FDA). If approved, this contraceptive ring would be the first ring to offer women a whole year of contraceptive protection and does not require refrigeration. Another innovative ring in the pipeline is the dapivirine ring developed by the International Partnership for Microbicides (IPM) to reduce risk of HIV infection. It is currently under review by the European Medicines Agency (EMA).
Just as exciting are the number of multi-purpose prevention technology (MPT) rings currently in the development pipeline—11 rings are in various stages of clinical research. They are multi-purpose because they offer multiple protections—for example, against STIs and pregnancy; multiple STIs; combination of STIs and HIV; pregnancy, STIs and HIV. The possibility of offering multiple benefits through a single product is exciting as it can offer benefits while reducing costs to users and health systems.
Making rings a reality
Rings are a new product category in many developing countries. The ability of vaginal rings to deliver on their promise to users, health systems, and markets will depend on the actions of a variety of stakeholders—product developers, policy makers, program managers, the private sector, and the development community at large.
Successes and lessons learned from the first rings to be introduced—Progering and Dapivrine—will be critical in informing the introduction of rings to follow. Often under-funded, this so-called “translational research” is a critical phase when insights from real world application become available–be it consumer and provider experience with the new technology or structural issues, such as market viability. Consistent and coordinated action by all stakeholders and support by donors during the translational research phase are essential. We here at the Population Council join peer organizations around the world in a commitment to translational research to ensure that every woman, everywhere has access to the widest possible range of innovative, high-quality contraceptive options.