One ring to stop them all

The vaginal contraceptive ring is used "three weeks on, and one week off".

Tired of remembering to take the Pill? Try this contraceptive device with similar hormonal effects.

PREGNANCY results when a sperm meets one of the eggs (ova) produced by the ovary.

Contraception aims to prevent this occurrence by stopping the ova production, or by keeping the sperm and egg apart.

The Pill, which is a hormonal contraceptive, is a safe and reliable method used by millions of women worldwide. It is the most popular contraceptive method in most countries.

The Pill is taken by mouth. Until a decade ago, this was the only method of taking hormonal contraception.

Then came the vaginal contraceptive ring. This device has been in use for about a decade, and became available in Malaysia a few years ago.

Since its introduction, many women have found it a useful contraceptive method, although it is – based on current trends – unlikely to be more popular than the Pill.

It is a soft transparent plastic ring about 4mm thick and 5.5mm in diameter that is placed inside the vagina for 21 days at a time. There is only one size.

Like the combined Pill, the vaginal ring contains two hormones, ie an oestrogen and a progestogen, which are similar to the ones made by the ovaries.

After the ring is inserted into the vagina, it is sited high up in the vaginal wall and releases the hormones continuously, slowly and steadily.

The hormones are absorbed through the vaginal lining, enter the bloodstream, and prevent eggs from being released by the ovaries. Without an egg, pregnancy cannot result.

The vaginal ring also thickens the cervical mucus, thereby preventing sperm from swimming up into the uterus, as well as thins the lining of the uterus, thereby decreasing the chances of a fertilised egg implanting into the uterus.

In short, the ring works in the same way as the oral Pill.

The vaginal ring is very effective and convenient to use.

When used according to instructions, ie it is kept in the vagina continuously for three out of every four weeks, less than one in 100 women will get pregnant in a year of use.

However, if the ring is left in the vagina for longer than three weeks, or it is not replaced with a new one after four weeks, the likelihood of pregnancy increases.

Advantages

The advantages of the vaginal ring far outweigh the risks in almost all women.

One ring will provide contraception for a month, so there is no need to think about it daily.

It rarely interrupts sex as one can have sex with the ring in the vagina.

Periods are likely to be regular, shorter and lighter. This reduces the likelihood of anaemia, in which there is a reduction in the haemoglobin, which transports oxygen in the blood.

The ring relieves menstrual cramps or pains, and symptoms of pre-menstrual syndrome (PMS).

Unlike the Pill, the ring is effective even if the user has vomiting or diarrhoea from any other cause.

Most healthy women who are non-smokers below 35 years of age can use the vaginal ring. It has been prescribed for healthy women until the age of 50.

Disadvantages

The vaginal ring can sometimes have side effects that are similar to that of the Pill.

These include vaginal irritation and discharge, breast tenderness, nausea, headache, abdominal discomfort, slight vaginal bleeding, acne, and possibly, mood changes.

Some users have complained about a reduction in sexual desire (libido). However, it is unclear whether this is an authentic side effect.

There are some risks associated with the ring, but they are small. The serious risks are clotting in the veins (deep vein thrombosis) and/or lungs (pulmonary embolism), heart attacks and strokes.

As such, the ring cannot be used by women who smoke and are above the age of 35 years, or who have ceased smoking in the past year; who have a history of blood clot in a vein or artery (thrombosis); heart or circulation conditions, including hypertension, diabetes, severe migraine with pre- warning symptoms (aura), liver or gall bladder disease and lupus; who are obese; who have a family history of strokes or heart attacks; and who are taking medicines that interact with the hormones in the ring, eg certain antibiotics and enzyme inducers, like medicines used to treat epilepsy and HIV, as well as St John's wort, a herbal remedy.

The vaginal ring cannot be used when breastfeeding, as it affects milk production.

It is inadvisable to use the ring if there is undiagnosed vaginal bleeding or possibility of pregnancy.

It may not be suitable if there are vaginal or cervical conditions.

Repeated childbirth may lead to laxity of the vaginal muscles, causing difficulty in keeping the ring in.

The jury is still out on whether the ring decreases or increases the risk of certain cancers, and whether it is related to small vaginal tears.

The ring does not provide protection against sexually transmitted infections.

A discussion with your doctor on the advantages and disadvantages of using the ring would assist in making an informed choice.

Using the ring

A consultation with the doctor is advisable prior to using the vaginal ring.

The doctor will evaluate the person's suitability for the ring, and provide information about possible side effects and advice on how to insert the ring.

Hands have to be washed, and the vaginal ring squeezed between a thumb and forefinger to narrow it.

The genital lips (labia) are held open with the other hand and the ring gently pushed into the vagina as high as possible.

The ring does not have to be positioned in any special location, neither does it have to cover the cervix, unlike caps and diaphragms.

The vaginal muscles will keep the ring in place during activities like exercise and sex.

The ring can't get lost inside the vagina because the cervix, which is located at the end of the vagina, prevents the ring from travelling up into the uterus.

Patients will be advised to insert the ring on the first day of their period when there is immediate protection against pregnancy.

If the ring is inserted later in the menstrual cycle, alternative contraception, eg condoms, will have to be used for the next seven days, as there will not be protection against pregnancy until then.

The ring loses its effectiveness after 21 days, and is removed by hooking a finger-tip around it and pulling it out.

After removal of the ring, there will be a week's break, during which there will probably be a period-like bleed. After that, a new ring will have to be inserted.

The routine is "three weeks on the ring and one week off".

The ring that has been removed can be placed in a bag and disposed of. It is inadvisable to throw it down the toilet as it would add hormones to the waste water system.

Other concerns

If the new vaginal ring is inserted more than 24 hours late, or has been removed for longer than three hours, eg during sex, the ring has to be inserted as soon as one remembers, and alternative contraception, eg condoms, used for the next seven days.

Emergency contraception (EC) should be taken if there is unprotected sex before contraceptive coverage is regained.

The vaginal ring is usually not felt by the user, and rarely poses problems with sex. The partner may feel the ring touching the tip of the penis, but it does not usually cause discomfort.

The hormones in the ring do not appear to affect the partner. However, it may be advisable to inform him that the ring is being used.

The ring sometimes gets displaced or is expelled during sex or when straining at defecation.

All that is needed is to rinse it in warm water and replace it within the next three hours, and it will not affect protection against pregnancy.

If the ring is out for more than three hours and there is unprotected sex, a consultation with the doctor would be advisable and EC considered.

Tampons can be used with the vaginal ring. However, it may come out when the tampon is removed.

In general, there will be no period during the three weeks while the ring is in place, so a tampon would be unnecessary.

Whether the contraceptive effect of the vaginal ring is impaired when commonly prescribed antibiotics are consumed, as is the case with the Pill, is still to be elucidated.

The vaginal ring is a useful contraceptive device.

It provides excellent protection against pregnancy when used in accordance with the instructions provided.

It can be used by most healthy women, except those who have conditions that render them unsuitable for the ring. Regular check-ups are advisable.

■ Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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