An Ultrasensitive (Parts-Per-Quadrillion) and SPE-Free Method for the Quantitative Analysis of Estrogens in Surface Water.

An analytical method is presented here that is sensitive to the parts-per-quadrillion (pg/L) for estrogens in surface water. The estrogens included for study were estrone, 17ß-estradiol, estriol, 17α-ethinylestradiol, and equilin. The method consisted of the small-scale liquid-liquid extraction of surface water followed by derivation with dansyl chloride. Analyte separation and detection were performed by high-pressure liquid-chromatography and tandem mass-spectrometry. A large volume (100 µL) of the sample was injected on-column to increase the analyte mass sent to the detector. The detection limits of the method were 0.045 ng/L for estrone, 0.086 ng/L for 17ß-estradiol, 0.030 ng/L for estriol, 0.049 ng/L for 17α-ethinylestradiol, and 0.13 ng/L for equilin. The whole-method accuracy ranged from 93 ± 5.8% to 105 ± 4.5% for all the analytes at two different spike levels. Similarly, the precision of the method was less than 8.0% relative standard deviation. The final method was used to analyze a series of samples from the Mississippi River spanning 51 river miles. Estrone was detected in all of the samples and 17ß-estradiol was detected in one. Concentrations of estrone ranged from between the detection and quantification limits up to 0.63 ng/L. Increases in the concentration of estrone could be observed downstream from potential sources including a drinking water treatment plant. 17ß-estradiol was detected below its quantitation limit in a sample taken downstream from a wastewater treatment plant.

The synthetic progestin levonorgestrel is a potent androgen in the three-spined stickleback (Gasterosteus aculeatus).

The use of progestins has resulted in contamination of aquatic environments and some progestins have in experimental studies been shown to impair reproduction in fish and amphibians at low ng L(-1) concentrations. The mechanisms underlying their reproductive toxicity are largely unknown. Some progestins, such as levonorgestrel (LNG), exert androgenic effects in mammals by activating the androgen receptor (AR). Male three-spined stickleback (Gasterosteus aculeatus) kidneys produce spiggin, a gluelike glycoprotein used in nest building, and its production is directly governed by androgens. Spiggin is normally absent in females but its production in female kidneys can be induced by AR agonists. Spiggin serves as the best known biomarker for androgens in fish. We exposed adult female sticklebacks to LNG at 5.5, 40, and 358 ng L(-1) for 21 days. Androgenic effects were found at LNG concentrations ≥40 ng L(-1) including induction of spiggin transcription, kidney hypertrophy, and suppressed liver vitellogenin transcription. These are the first in vivo quantitative data showing that LNG is a potent androgen in fish supporting the contention that androgenic effects of certain progestins contribute to their reproductive toxicity.

RP-HPLC method validation for fast extraction and quantification of Levonorgestrel drug from silicone based intrauterine device intended for in-process and finished formulation.

BACKGROUND: To develop and validate a simple and consistent reversed phase high performance liquid chromatography (RP-HPLC) method for the estimation of Levonorgestrel (LNG) drug from silicone based intrauterine device. METHODS: Sample solution was prepared using tetrahydrofuran (THF) as solvent for the drug extraction, and RP-HPLC analysis was performed using Luna C18 analytical column (150 × 4.6 mm, 5 µm, 100 Å - Phenomenex), with a mobile phase consisting of a mixture of acetonitrile and water (50:50, v/v) at a flow rate of 1.0 ml/min and injection volume of 20 µl. Detection was carried out at 241 nm in PDA detector, with a total run time of 15 min. The method was validated in accordance with ICH guidelines. Method applicability was tested for optimizing formulation using quality-by-design approach, to check the stability and content uniformity of levonorgestrel-silicone mixture (core blend), and quantifying the amount of LNG from commercially available silicone based formulation. RESULTS: The retention time for LNG drug was obtained at 8.5 min (± 0.3 min). A linear relationship was observed over the concentration range of 2.6-15.6 µg/ml with the correlation coefficient (r) value 0.9999. The method was found to be precise within the acceptable limit (RSD < 2%) and the drug recovery from the intrauterine device was found in the range 99.78-100.0%. Content uniformity for different prototypes developed was observed in the range of 91.6-101.4%, and assay of optimized core blend was in the range of 97.78-106.79% during the 10 days of retention period for stability studies. CONCLUSION: The validated method is found to be a simple, accurate, precise, reproducible, and hence can be used for the routine analysis of LNG such as in-process, quality control and stability assays of silicone based intrauterine devices by RP-HPLC.

Elution from intact and broken vaginal contraceptive rings: an in vitro study.

OBJECTIVE: The in vitro elution of the active substances etonogestrel (ETO) and ethinylestradiol (EE) of Ornibel® (a vaginal delivery system) was determined after a deliberate breakage of the vaginal contraceptive ring and compared to the standard elution and hormone release of intact rings under the same experimental conditions. MATERIALS AND METHODS: Ornibel® intact and broken vaginal rings were placed in a dissolution buffer and subject to a repetitive sampling of ETO and EE following a standardized in vitro elution (IVE) procedure for 21 days. The hormone dissolution profile was determined by HPLC using a fully validated analytical method. In a second study, rings were broken after day seven, and their elution profiles were compared to that of intact rings. For all utilized batches, the stability conditions established were 24 months at 5°C. Furthermore, no special storage conditions are needed. RESULTS: The instantaneous elution on day 1 of ETO and EE for intact rings were 119±8 µg/day and 15±1 µg/day, respectively (mean ± SD), which was non-significantly different to the immediate release of ETO and EE for broken rings (118±4 µg/day and 14±1 µg/day). The average elution profile for days 2-20 were 132±5 µg/day and 18±1 µg/day (ETO/EE, intact rings) and 132±4 µg/day and 19±1 µg/day (ETO/EE, broken rings) respectively. On day 21, the elution of ETO and EE was numerically similar 111±5 (±4) µg/day and 18±1 µg/day) for both intact and broken rings. The IVE results from intact rings and vaginal rings deliberately cut on day seven similarly did not differ in their release of ETO and EE. CONCLUSIONS: Our study concludes that the hormonal release of ETO and EE from Ornibel® are similar for intact and broken vaginal rings under standardized in vitro conditions.

Post-use ring weight and residual drug content as potential objective measures of user adherence to a contraceptive progesterone vaginal ring.

OBJECTIVES: The primary aim was to investigate post-use ring weight as a potential measure of cumulative adherence to a progesterone-releasing vaginal ring. STUDY DESIGN: We weighed and quantified residual progesterone in 115 vaginal rings following 90-day use by participants in an acceptability trial conducted in Nigeria, Senegal and Kenya. The primary objective was to correlate residual progesterone content with post-use ring weight. Secondary objectives included correlating ring weight with putative duration of ring use, and, where participants used two rings consecutively in the study, correlating residual content between these paired rings. RESULTS: Mean ring weight and progesterone content of used rings was 8.62±0.24 g and 1245±245 mg respectively, versus 9.37±0.02 and 2058±21 mg for control rings. Most used rings (90.4%) had residual progesterone levels less than 85% of the nominal loading. Linear regression showed a strong positive linear trend between residual progesterone content and post-use ring weight for all rings (r2=0.82). Duration of ring use was inversely associated (p=.00020) with ring weight. CONCLUSIONS: Post-use ring weight is highly correlated with residual progesterone content, a benchmark objective cumulative measure of adherence, and thus potentially useful as a surrogate objective measure of cumulative adherence to a progesterone-releasing vaginal ring. IMPLICATION STATEMENT: For vaginal rings containing a high initial drug loading and releasing a relatively large fraction of the initial loading during clinical use, post-use ring weight may offer a simple and inexpensive alternative to residual content testing for accurate monitoring of user adherence.

Breast levonorgestrel concentrations in women using a levonorgestrel-releasing intrauterine system.

OBJECTIVE: To measure breast tissue and serum LNG concentrations in women using a LNG-IUS. STUDY DESIGN: This pilot study was performed in 25 healthy women undergoing breast surgery at the Ghent University hospital. LNG concentrations were measured in serum and microdissected breast tissue samples using a validated ultra-performance liquid chromatography/tandem mass spectrometry assay. RESULT(S): The mean LNG concentration in the 18 LNG-IUS users was 0.18±0.16 ng/mL in serum and 0.26±0.28 ng/g in breast tissue. For four women without any form of hormonal contraceptive (the negative controls), the mean concentrations were below the limit of quantification, i.e., 0.15 ng/mL and 0.20 ng/g, for serum and breast tissue, respectively. For the three positive controls the concentrations in the serum (20.5 and 3.4 ng/ml) and the breast (3.74 and 1.24 ng/g) were respectively for the 20 µg EE/100 µg users and 315 pg/ml in the serum and 1.17 ng/g in the breast for the minipill user. The intracellular free fraction of LNG may be as low as 0.008 ng/g. CONCLUSION(S): The concentration of LNG in breast epithelium cells in women using the LNG-IUS is very low. IMPLICATIONS: The relationship between the serum and breast tissue levels of LNG was studied in women using a LNG-IUS or oral LNG-containing contraception. Compared to oral contraception, the tissue levels of LNG in LNG-IUS users are much lower in the breast. It is not known what level of LNG exposure in the breast would stimulate RANKL and WNT4 expression; such information is needed.

[Sonographic localization of non-palpable implanon hormone implants]. / Sonografische Lokalisation nicht tastbarer Implanon(R)-Hormonimplantate.

PURPOSE: Implanon is a rod-shaped hormone implant which leads to reliable contraception. The rod is implanted in the subcutis of the upper arm and is usually removed easily after its effective period. In the scenario where the rod is not palpable, the removal of the rod can be difficult or impossible. The purpose of this study was to evaluate the reliability of US in locating non-palpable Implanon implants and to investigate the optimal technical parameters for determining the location. MATERIALS AND METHODS: In a prospective study we evaluated 21 women between June 2004 and June 2008. In 14 patients previous examinations with US, radiography, CT and/or MRI were non-diagnostic. The US evaluation followed a standardized protocol in transverse and longitudinal sections. The technical parameters US frequency, position and number of focal zones and compound imaging were varied to define the optimal parameters for the visualization of the Implanon implant. RESULTS: The Implanon implant was detected in all 21 patients. Reasons for negative palpability were mainly an intramuscular or subfascial location as well as a significant migration of the Implanon implant in 2 patients. The use of a high US frequency, the position of the focal zones in the near field and the deactivation of compound imaging all facilitate visualization of the characteristic US morphology of the plastic rod. CONCLUSION: High resolution US is the method of choice for determining the location of non-palpable Implanon implants. Knowledge of US morphology and optimal technical settings as well as the use of high-resolution scan heads are essential for determining the correct location.

Pregnancy interceptive activity of the roots of Calotropis gigantea Linn. in rats.

OBJECTIVE: We conducted this study to evaluate the pregnancy interceptive activity of the roots of Calotropis gigantea Linn. in colony-bred adult Sprague-Dawley rats when administered during the preimplantation and/or peri-implantation periods. METHODS: The ethanolic extract of the roots of C. gigantea Linn. and its hexane, chloroform, n-butanol-soluble and n-butanol-insoluble fractions were administered to rats on Day 1, Days 1-5, Days 1-7 or Days 5-7 postcoitum. Rats from the control group received an equal volume of the vehicle (Tween 80 in glass distilled water) only. At autopsy on Day 10 postcoitum, the final body weight and number as well as status of the corpora lutea and implantations in each animal were recorded. For estrogen agonistic and antagonistic activities, 21-day-old immature rats ovariectomized 7 days earlier were treated orally with the test agent or the vehicle for 3 days. In the case of estrogen antagonistic activity, the rats also received 0.05 mg/kg of 17alpha-ethinyl estradiol for 3 days. At autopsy 24 h after the last treatment, uterine fresh weight was taken and premature opening of the vagina as well as the extent of vaginal cornification, if any, were recorded. RESULTS: The ethanolic extract of the roots of C. gigantea Linn. exhibited 100% pregnancy interceptive activity in rats when administered as a single oral dose of 100 mg/kg on Day 1 postcoitum. The extract also exhibited 100% efficacy at the dose of 12.5 mg/kg when administered in the Days 1-5 and 1-7 postcoitum schedules. When administered during the peri-cum-early postimplantation period (i.e., Days 5-7 postcoitum at 250 mg/kg), most of the implantations showed signs of resorption. On fractionation, the chloroform fraction showed 100% activity at 100 mg/kg in the single-day (Day 1 postcoitum) schedule, whereas the hexane, n-butanol-soluble and n-butanol-insoluble fractions were found to be inactive at this dose. At autopsy on Day 10 postcoitum, 7-25% loss in body weight was recorded at the minimum effective contraceptive dose (MED) in rats treated with the ethanolic extract as well as its chloroform-soluble fraction on Days 1-7, 1-5 and 1 postcoitum, in comparison with the 6-7% increase in body weight observed in vehicle control rats. There was however no mortality in any of the treatment groups. The active ethanolic extract and its chloroform fraction were devoid of any estrogen agonistic or antagonistic activity at their respective MEDs in the ovariectomized immature rat bioassay. Efforts are being made to isolate the active principles devoid of effect on body weight. CONCLUSIONS: The findings suggest the potential for developing products of this plant as contraceptives for human use and welfare. In addition, characterization of the agents responsible for body weight decrease and evaluation of their mechanism of action and safety profile, with or without contraceptive efficacy, might have added advantage for the management of obesity.

Residual hormone levels in used contraceptive rings as a measurement of adherence to vaginal ring use.

OBJECTIVE: This study sought to measure residual contraceptive hormone levels in vaginal rings as an adherence marker for monitoring product use in clinical trials. STUDY DESIGN: Residual etonogestrel and ethinyl estradiol levels from used NuvaRings® of 26 self-reported adherent women enrolled in a clinical trial of vaginal ring acceptability were compared to those from 16 women who used NuvaRing® as their contraceptive choice. RESULTS: Twenty-one (81%) clinical trial rings had contraceptive hormone levels within the range of those used as a contraceptive choice. Five returned rings had unused or discordant levels of residual contraceptive hormones. CONCLUSION: Residual vaginal ring drug levels could help assess adherence in clinical trials.

Amino acid constitution of the contraceptive polypeptide from hamster zygotes.

A final separation, on Sephadex G-10, of a biologically active fraction from hamster zygotes has been achieved. The compounds acts to prevent ovulation when it is injected into nonbred hamsters. The active fraction has been analyzed and found to consist of four amino acids: arginine, lysine, proline, and threonine.

PIP: The isolation and analysis of a polypeptide from hamster zygotes during the early stages (2-cell) of pregnancy is reported. A high purification was achieved on the Sephadex G-10. Subcutaneous injection of the extract into unbred hamsters acts to prevent ovulation even though psychic estrus is present. The fraction was found to consist of 4 amino acids: arginine, lysine, proline and threonine, which seem present in equal amounts.

Quantitative analysis of nonoxynol-9 in blood.

At present, there is little data on the level of nonoxynol-9 (N-9) in blood. Using routine methods, the rate of recovery for N-9 in blood has been confirmed to be very low. A method determining N-9 levels in urine has been found but obviously a more efficient method for determining N-9 levels in blood and urine is still needed. Here, a method of determining N-9, a nonionic surfactant spermicide, in blood is presented. The analytical procedure is a simple and convenient method. Using HPLC, UV detector, ODS reversed-phase column, methanol-water mobile phase, NaCl salting-out and two extractions with benzene, a rate of recovery for N-9 of 93 +/- 4% has been obtained.

An evaluation of the amount of nonoxynol-9 remaining in the vagina up to 4 h after insertion of a vaginal contraceptive film (VCF) containing 70 mg nonoxynol-9.

The objectives of this study were to determine the amount of nonoxynol-9 (N-9) remaining in the vagina 30 min and 1, 1.5, 2, and 4 h after vaginal insertion of a single sheet of VCF containing 70 mg N-9 and to compare these results to the manufacturer's instructions for use of this product. A new method of vaginal lavage was used to obtain samples for N-9 determination. This was an open-label, noncomparative, pharmacokinetic study in 12 healthy women volunteers not at risk for pregnancy. The study consisted of a screening visit followed by five test visits approximately 1 month apart and a final visit 1 week after all test visits were completed. At each test visit, the investigator inserted a single sheet of VCF in the vagina of the volunteer at midcycle. The volunteer remained in the clinic and underwent vaginal lavage with normal saline after one of five specified time intervals had elapsed. The sequence of the intervals completed by each volunteer was determined by randomization. When undissolved film was found in the vagina, it was removed prior to lavage and assayed for N-9 content separately from that recovered in lavage fluid. It was assumed that the N-9 in undissolved film would not contribute significantly to sperm immobilization. Between 18.5 and 28.5 mg of N-9 were recovered in lavage fluid after intervals of 0.5, 1, 1.5, and 2 h. These levels did not differ statistically (p > 0.05). The amount of N-9 recovered dropped significantly at 4 h to 11.0 mg. If it is assumed that an N-9 concentration of 0.100 mg/mL is required to immobilize sperm in vitro, this study suggests that the amount of N-9 remaining in the vagina in the form of dissolved film up to 4 h after insertion of VCF is sufficient to immobilize sperm. The lavage procedure may not have recovered all N-9 remaining in the vagina. However, intercourse did not take place between insertion and lavage; if it had, the proportion of the film remaining undissolved and the total amount N-9 remaining in the vagina at the time of examination might have been affected.

PIP: The amount of nonoxynol-9 (N-9) remaining in the vagina 0.5, 1.0, 1.5, 2.0, and 4.0 hours after vaginal insertion of a single sheet of a contraceptive film (VCP) containing 70 mg of N-9 was investigated in a pharmacokinetic study involving 12 US women. At each of 5 test visits, approximately 1 month apart, a single sheet of VCF was inserted at midcycle. Vaginal lavage with normal saline was then performed after 1 of the 5 specified time intervals had elapsed. At 30 minutes, an average of 34.4 mg (49% of the total N-9) could be recovered. After intervals of 1.0, 1.5, and 2.0 hours, 18.5-28.5 mg of N-9 was recovered in lavage fluid. The amount of recovered N-9 dropped significantly to 11.0 mg after 4.0 hours. It is assumed that an N-9 concentration of 0.100 mg/mL is required to immobilize sperm. Thus, the amount of N-9 remaining in the vagina up to 4.0 hours after insertion of VCF is sufficient for contraception. The VCF label states that intercourse may take place 15 minutes after film insertion. Although lavage was not performed at this time point, it can be assumed that at least 49% of the original N-9 would be present. Since this study is limited by the fact that intercourse did not take place, future studies should include postcoital measures of the amount of N-9 persisting at various intervals.

Pharmacodynamic effects of depot-medroxyprogesterone acetate (DMPA) administered to lactating women on their male infants.

Normal postpartum women, who had a spontaneous vaginal delivery of one full-term male infant, free of congenital abnormalities and other diseases, were recruited for this study. Thirteen women received 150 mg depot-medroxy-progesterone acetate (DMPA), intramuscularly on days 42 + 1 and 126 + 1 postpartum. Infants of nine mothers, who did not receive DMPA, served as controls. Blood samples were collected from treated mothers on days 44, 47, 74, 124, 128, and 130 postpartum for medroxyprogesterone acetate (MPA) measurements. Four-hour urine collections were obtained from all 22 infants in the morning on days 38, 40, 42, 44, 46, 53, 60, 67, 74, 88, 102, 116, 122, 124, 126, 128, 130, and 137. Urinary follicle stimulating hormone (FSH), luteinizing hormone (LH), unconjugated testosterone, and unconjugated cortisol were measured by radioimmunoassay, and serum MPA and urinary MPA metabolites were measured by gas chromatography-mass spectrometry (GC-MS). No MPA metabolites could be detected in the urine of the infants from the DMPA-receiving mothers. Hormonal profiles in the urine samples were not suppressed in comparison with those of the control infants. The present study demonstrates that DMPA, administered to the mother, does not influence the hormonal regulation of the breast-fed normal male infant.

Metabolic parameter, bleeding, and weight changes in U.S. women using progestin only contraceptives.

Our objective was to determine the effect of progestin-only contraceptives on metabolic parameters, bleeding patterns, and weight changes during the first year of use. Seventy-one women (> 95% Caucasian), who were advised regarding contraception alternatives, self-selected levonorgestrel implants (n = 44), depo-medroxyprogesterone acetate (n = 22), or oral norethindrone (n = 5). One year later, 11 levonorgestrel implant and five depomedroxyprogesterone acetate patients were randomly selected to compare (pre- and post-progestin use) levels of cholesterol, triglycerides, low density lipoprotein (LDL), high density lipoprotein (HDL), very low density lipoprotein (VLDL), apolipoproteins A-1 and B-100, bilirubin, and sex hormone binding globulin. Monthly bleeding and spotting records were kept in each group. Body weights were also monitored in each group. No statistically significant differences in metabolic parameters were found between pre- and post-progestin use in the levonorgestrel implant and depo-medroxyprogesterone acetate groups. Continued bleeding patterns were more prominent in the levonorgestrel implant and oral norethindrone groups than in patients receiving depo-medroxyprogesterone acetate. No significant weight gain was detected in any group. No changes in metabolic parameters or weight were noted over the one year of use of levonorgestrel implants or depo-medroxyprogesterone acetate. Depo-medroxyprogesterone acetate had the highest incidence of amenorrhea.

PIP: During March 1991-April 1992, health workers recruited 71 women aged 16-43 (98% Caucasian) attending the University of Utah Obstetrics and Gynecology Clinic for a clinical study examining metabolic parameters, menstruation disorders, and changes in weight after 12 months of use of a progestin-only contraceptive. The progestin-only contraceptives (number of women using each) included Norplant contraceptive implants (44), Depo-Provera (22), and a mini-pill (norethindrone) (5). Metabolic parameters were total cholesterol, triglycerides, high density lipoprotein (HDL), low density lipoprotein (LDL), very low density lipoprotein (VLDL), sex hormone binding globulin, apolipoprotein A-1, apolipoprotein B-100, and total and direct bilirubin. The only groups investigated for metabolic parameters were Norplant users and Depo-Provera users. Metabolic parameters did not change significantly after progestin use. No group experienced significant weight gain. However, one woman gained more than 60 pounds in the Norplant group and one woman gained more than 40 pounds in the Depo-Provera group. Depo-Provera users had significantly fewer total days of blood loss than Norplant users during months 5-12 (p 0.02) and mini-pill users during months 6-10 (p 0.04). Mini-pill users and Norplant users had similar bleeding patterns, except during months 11-12, when Norplant users had more bleeding than mini-pill users (e.g., month 12, 9 vs. 0 days). The total days of blood loss was 8.7 for Norplant users, 3.5 for Depo-Provera users, and 10.2 for mini-pill users. Less than 10% of Norplant users and mini-pill users experienced amenorrhea, while amenorrhea increased after 120 days in Depo-Provera users (p 0.001). After 1 year, the Norplant and mini-pill groups had more excessive prolonged (10 days) bleeding than the Depo-Provera group (29% and 50%, respectively, vs. 11%).

Residues of medroxyprogesterone acetate detected in sows at a slaughterhouse, Madagascar.

In Madagascar, little information about drug residues in animal products is available. However, recently, official veterinary services were informed about the misuse of human injectable contraceptives in pig farms as an alternative for chirurgical castration of adult sows before culling. We investigated pigs (n = 80) slaughtered in 7 Malagasy abattoirs and raised in 8 of the 22 Malagasy regions (1) to confirm the contamination of carcasses by anabolic hormones by using LC-MS/MS, (2) to identify the substances of concern and (3) to explore the consumers' exposure to hormone residues. Medroxyprogesterone acetate was the only synthetic hormone detected in kidney fat. Samples positive with medroxyprogesterone acetate were observed in 66.7% of the districts investigated and in 87.5% of the surveyed regions, confirming its large misuse in livestock. Public awareness campaigns and control improvement among the animal production sector and among the Malagasy public health sector are therefore urgent.

The contraceptive vaginal ring in women with renal and liver transplantation: analysis of preliminary results.

INTRODUCTION: Vaginal administration seems to be the best route to achieve steady and precise doses of contraceptive hormones, resulting in stable serum concentrations and low exposure. The aim of this study was to evaluate the contraceptive efficacy, cycle control, tolerability and acceptability of a contraceptive vaginal ring (NuvaRing) in renal and liver transplant recipients. MATERIAL AND METHODS: Renal or liver transplant recipients, asking for contraception, were enrolled into the study. The duration of treatment was 12 cycles, with each vaginal ring releasing an average of 120 mg etonogestrel and 15 mg ethinylestradiol daily. Study visits were scheduled at screening, in the first week following cycles 3, 6, and 12 (172 cycles). RESULTS: Among 17 females included into the study: were 9 renal (mean age, 30 +/- 7.2 years) and 8 liver transplant recipients (mean age, 32.6 +/- 6.6 years). At the onset of therapy all patients showed at least 6 months of stable graft function with no signs of allograft rejection. The mean posttransplant follow-up was 4 +/- 3.6 and 5.3 +/- 2.1 years for women with renal and hepatic transplantations respectively (P = NS). The immunosuppressive therapy was not changed for any patient. We demonstrated good cycle control: 162 cycles did not exhibit any bleeding; 7 cycles, only spotting episodes, whereas 2 cycles had 1 bleeding episode during the ring period. The estrogen-related adverse events (nausea and breast tenderness) were reported in 2 patients. One patient experienced significant bleeding related to thrombocytopenia. DISCUSSION: Nuvaring, in our preliminary findings, may be considered to be an highly effective contraceptive method for female transplant recipients that additionally regulate menstrual bleeding and seems to positively influence well-being. Vaginal administration may diminish the chance of drug interactions and therefore be safer for patients.