What Is A Vaginal Ring? 

In the realm of modern contraception and hormone management, vaginal rings have emerged as a game-changing option. These small, flexible devices, often overlooked compared to more widely known birth control methods, offer a unique combination of effectiveness and ease of use.

Vaginal rings have emerged as a game-changing option in modern contraception and hormone management due to their high effectiveness, user convenience, and reduced systemic side effects. These flexible devices provide a steady release of hormones locally within the vagina, offering reliable pregnancy prevention without the need for daily administration. Their ease of use, discreet nature, and potential non-contraceptive benefits make them an appealing choice for many individuals, transforming the landscape of women's healthcare.

As we delve further into the fascinating realm of vaginal rings, there's much more to uncover. Whether you're seeking a deeper understanding of how these devices work, exploring their various types, or considering their implications for women's health, we have extensive insights and information waiting for you. Join us on this educational journey as we continue to unravel the complexities and advantages of vaginal rings in the context of contraception, hormone therapy, and beyond. Keep reading to discover a wealth of knowledge that can empower your understanding of this essential facet of women's healthcare.

What is a vaginal ring?

A vaginal ring is a flexible, circular device made of plastic, silicone or other materials that is inserted into the vagina. It is designed to release hormones, act as a physical barrier or deliver medications locally. There are two types of vaginal rings: hormonal rings that release hormones for contraceptive or hormone replacement therapy (HRT) purposes and non-hormonal rings that provide a physical barrier for contraception.

Types of vaginal rings

Hormonal vaginal rings

Hormonal vaginal rings typically contain synthetic hormones, which are released in a controlled and steady manner into the vagina and are absorbed into the body through the vaginal lining.¹ Similar to most birth-control pills, the rings contain the hormones estrogen and progestin. The commercially available hormonal vaginal rings include:

1. Strogen-Progestin Combination Rings
2. Progestin-Only Rings

Progestin, aka progestogen, is a synthetic form of the endogenous hormone progesterone, which is primarily responsible for preventing pregnancy.³ It inhibits follicular development and prevents ovulation by inducing negative feedback at the hypothalamus. Estrogen also inhibits follicular development by causing a similar negative feedback on the anterior pituitary. The lack of oestrogen-positive feedback combined with the progesterone-negative feedback stops the luteinising hormone surge, essential for the release of the follicle, hence suppressing ovulation. This mechanism of action is commonly exploited in Estrogen-Progestin combination Rings.²

The most popular commercially available Estrogen-Progestin Combination ring is the NuvaRing marketed by Merck. Other generic alternatives include EluRyng, Femring and Estring.^4,7

Progesterone is also capable of inducing endometrial atrophy (which prevents implantation) and thickening cervical mucus to inhibit the penetration of sperm through the cervix and upper genital tract. Progestin-only rings are mainly designed for use by breastfeeding women as an alternative to using synthetic hormones that could affect the infant(3). The most popular commercially available Progestin-only ring is the Progering.

Hormonal vaginal rings are highly effective (comparable to birth control pills) at preventing pregnancy when they are used correctly. In addition to contraception, they are also prescribed for HRT to effectively manage menopausal symptoms such as hot flashes, vaginal dryness and mood swings.

Mechanism of hormone release

The hormonal rings rest against the vaginal walls, allowing the synthetic hormones to come in contact with the vaginal mucosa directly. The highly vascularized mucosal layer allows the permeation of the hormones into the bloodstream and enters circulation. The unique design of the vaginal ring ensures a consistent and steady release of hormones over time, hence maintaining a continuous level of hormones in the bloodstream to achieve the desired therapeutic effects.³ 

How are hormonal vaginal rings used?

Vaginal rings are commonly used for a period of three weeks. After this period, the ring can either be replaced or removed for a week-long break. During the break week, the hormone levels have been observed to drop temporarily, stimulating a menstrual cycle. This is called the withdrawal bleed. A new ring can be inserted after the break week to reinstate the contraceptive of HRT effects. This cyclic pattern ensures that the hormone release mechanism remains effective throughout the prescribed period of use. Individuals can also take a break a few times a year rather than every month or have no breaks or bleeds, known as back-to-back use.⁸

Although a person can start using the vaginal ring at any time during their menstrual cycle, it is recommended to initiate its use in the first five days of the cycle. Vaginal rings take seven days to become fully effective. Hence it is recommended to use additional contraception (like condoms) if the ring is inserted after day five of the menstrual cycle. The hormones released by the ring gradually build up in the system over time, thereby reducing levels of hormonal protection during the initial week of the cycle(9). 

Non-hormonal vaginal rings

Non-hormonal vaginal rings act as contraceptive devices without the use of hormonal substances. They are made of materials that either create a physical barrier or contain spermicides. The barrier effect involves a soft, closed ring that covers the cervix, preventing sperm from entering the uterus and reaching the egg. Spermicides are chemicals that immobilise or kill the sperm upon contact. Non-hormonal vaginal rings with spermicides slowly release the chemical over time to provide contraceptive protection. Although considered to be less effective than the hormonal method, these types of vaginal rings are generally effective at preventing pregnancy when used correctly.¹⁰ 

New and emerging options

1. Dapivirine Vaginal Ring - A vaginal ring designed to protect against HIV, containing the antiretroviral drug dapivirine¹¹
2. Annovera - A combined hormonal contraceptive vaginal ring that contains both estrogen and progestin hormone¹²
3. Intravaginal rings or capsules - A type of vaginal ring that can remain in place for extended durations, such as three months or a year. This allows for reducing the frequency of ring replacements¹³ 
4. Biodegradable rings - Vaginal rings designed to break down and dissolve over time¹⁴ 
5. Remote-controlled rings - A concept of vaginal rings that allow users to activate or deactivate the contraceptive methods using a remote control device¹⁵
6. Temperature monitoring rings - Similar to the vaginal rings, these are integrated with temperature sensors to monitor basal body temperature. They can be utilised for tracking fertility for natural family planning¹⁶

Vaginal ring insertion

1. Clean hands thoroughly before use and choose a comfortable position for insertion (standing with one leg raised/squatting/lying down).
2. Ensure the vaginal ring is not damaged or deformed when removed from its packaging.
3. Squeeze the vaginal ring between the thumb and index finger to make it more compact, and insert the folded ring into the vagina. Aim for a position that is deep enough to be secure and comfortable but also allows easy removal.
4. Use your fingers to ensure the correct position once the ring is inside. Readjust position in case of discomfort or pressure. Clean hands upon completion¹⁶ 

The vaginal ring can be removed after three weeks and disposed of. Once inserted, the ring is generally not noticeable to the partner during intercourse. Regular use of tampons is also not inhibited by the presence of the ring. It is possible that the ring may expel on its own, either during sex or if the ring is not positioned correctly. It is recommended to follow a cyclic pattern to avoid forgetting to replace the ring after the seven-day break. Avoiding the use of a new ring for over a duration of nine days can initiate ovulation, hence increasing the risk of pregnancy.

Impact of vaginal rings on the menstrual cycle

The use of vaginal rings, particularly hormonal ones, impacts the menstrual cycle, and the changes may vary significantly among individuals. Some of the commonly reported effects include the following.

1. Reduced menstrual flow
2. Shorter periods (in comparison to their normal menstrual cycle)
3. Improved cycle regularity for individuals with irregular menstrual cycles due to hormonal imbalances.
4. Hormone-induced stabilisation of the uterine lining reduces the intensity of menstrual cramps.
5. Possible irregular bleeding or spotting during the first months of using a hormonal vaginal ring.

Non-hormonal vaginal rings are less likely to affect the menstrual cycle as they do not contain hormones.¹⁷

Other uses of vaginal rings

In addition to contraception and HRT, vaginal rings can also be prescribed for:

1. Menstrual cycle regulation

The hormones can be utilized to reduce heavy menstrual bleeding and cramps and also to regularise the period frequency and timings, mainly in individuals with irregular menstrual cycles. Vaginal rings can also be used for menstrual suppression in individuals who prefer fewer or no menstrual periods.¹⁶ 

2. Managing menstrual disorders

Non-contraceptive benefits of vaginal rings are gaining more popularity now. For instance, they are known to reduce the risk of ovarian cysts and endometriosis-related pain and improve polycystic ovary syndrome (PCOS) symptoms as well.¹⁶

Advantages and disadvantages of vaginal rings

Advantages

• High contraceptive efficacy

When used correctly and as prescribed, vaginal rings are highly effective at preventing pregnancy. The efficacy is often comparable with that of birth control pills.

• User friendly

Vaginal rings are easy to use and insert, providing convenience and privacy.

3. Long-acting contraception

Vaginal rings like Annovera can be used for up to a year with proper care, reducing the need for frequent replacements.

4. Cycle control

The use of vaginal rings regulates menstrual cycles, reduces heavy bleeding and cramps and also improves period regularity. This helps improve the quality of life for individuals with irregular menstrual cycles.

5. Reduced hormonal side effects.

As the hormones are released locally in the vaginal area, vaginal rings may result in fewer systemic side effects compared to birth control pills.

6. Privacy and Discretion

Vaginal rings are discreet and not externally visible.

7. Non-Interference with Daily Activities

Once inserted, the vaginal ring typically does not interfere with daily activities, including exercise, swimming, or sexual intercourse.

8. Flexible Usage Schedule

Vaginal rings often have a flexible usage schedule, allowing users to have a break week for withdrawal bleeding or to skip the break week to suppress menstruation, depending on their preferences and healthcare provider's recommendations.

9. Reduced Risk of User Error

Vaginal rings are associated with a lower risk of user error compared to some other methods, like birth control pills, which must be taken daily.

Disadvantages

1. Possible Side Effects

Vaginal rings can cause side effects, which may include breast tenderness, mood changes, headaches, and nausea. These side effects are often mild and tend to improve with time, but they can bother some users.

2. Vaginal Discomfort

Some individuals may experience vaginal discomfort, irritation, or discharge while using a vaginal ring. These symptoms are typically mild and temporary, but they can be a source of discomfort.

3. Insertion and Removal

Some may have difficulty or discomfort during insertion and removal of vaginal rings. Proper education and practice can help mitigate this issue.

4. Not Suitable for All Women

Vaginal rings are not suitable for everyone. Women with certain medical conditions, such as a history of blood clots, breast cancer, or uncontrolled high blood pressure, may be advised against using hormonal vaginal rings due to potential health risks.

5. User Compliance

Vaginal rings require regular replacement or removal and reinsertion, depending on the specific product. User compliance is crucial for their effectiveness. Forgetting to replace the ring on time or improperly inserting it can reduce its contraceptive efficacy.

6. Prescription Requirement

Vaginal rings typically require a prescription from a healthcare provider, which may involve medical examinations or consultations. 

7. Cost

The cost of vaginal rings can be relatively high, especially for those without insurance coverage. Cost considerations may limit their accessibility to some individuals.

8. Potential Impact on Menstrual Cycle

While many users experience positive changes in their menstrual cycle with vaginal rings, others may experience irregular bleeding or spotting during the adjustment period.

9. Non-Hormonal Options

Hormonal vaginal rings are not suitable for individuals who prefer non-hormonal contraceptive methods, and non-hormonal vaginal rings may be less effective at preventing pregnancy.

10. Allergic Reactions

In rare cases, individuals may be allergic to the materials used in vaginal rings, leading to discomfort or allergic reactions.

11. Privacy Concerns

While vaginal rings are discreet, some individuals may still have privacy concerns related to using this form of contraception.

Conclusion

In conclusion, vaginal rings have emerged as a transformative force in the realm of modern contraception and hormone management. These unassuming, flexible devices offer a unique blend of efficacy, convenience, and reduced systemic side effects, reshaping the landscape of women's healthcare. As ongoing research charts new horizons in vaginal ring development, it becomes evident that they are not just contraceptive tools but comprehensive solutions for women's diverse reproductive health needs.

Vaginal rings empower individuals in their family planning journeys. Their high contraceptive efficacy, ease of use, and privacy offer newfound agency to women in making informed choices about when and how to start or expand their families. With the ability to regulate menstrual cycles and manage menstrual disorders, vaginal rings also provide the means to reclaim control over one's reproductive health.

Beyond contraception, vaginal rings play a pivotal role in enhancing overall women's health. They have the capacity to alleviate menstrual discomfort, reduce heavy bleeding, and even improve the quality of life for those with irregular menstrual cycles. For women experiencing the challenges of menopause, these rings offer relief from symptoms like hot flashes and vaginal dryness. Moreover, as research progresses, the potential applications of vaginal rings in areas such as HIV prevention and extended-duration contraception underscore their enduring importance in women's healthcare.

In a world where reproductive choices are a fundamental right, vaginal rings have emerged as a symbol of empowerment, a means for women to take charge of their fertility and overall well-being. Their versatility, convenience, and ongoing advancements ensure that they remain a dynamic and indispensable option in the ever-evolving landscape of women's reproductive health. As we celebrate the remarkable journey of vaginal rings, we anticipate even greater strides ahead, enriching the lives and choices of women around the world.