title: Frequency and management of breakthrough bleeding with continuous use of the transvaginal contraceptive ring: a randomized controlled trial.
abstract: OBJECTIVE
  To assess bleeding patterns with continuous use of the transvaginal contraceptive ring.
  
  
  METHODS
  We did a prospective analysis of daily menstrual flow during a 21/7 cycle followed by 6 months of continuous use and institution of a randomized protocol to manage breakthrough bleeding/spotting. Seventy-four women completed the baseline 21/7 phase and were randomized equally into two groups during the continuous phase. Group 1 was instructed to replace the ring monthly on the same calendar day with no ring-free days. Group 2 was instructed to use the same process, but if breakthrough bleeding/spotting occurred for 5 days or more, they were to remove the ring for 4 days, store it, and then reinsert that ring.
  
  
  RESULTS
  Sixty-five women completed the continuous phase with reduced average flow scores in the continuous phase compared with the 21/7 phase (P<.02). Most patients had no to minimal bleeding during continuous use, with group 2 experiencing a statistically greater percentage of days without breakthrough bleeding or spotting (95%) compared with group 1 (89%) (P=.016). Instituting a 4-day hormone-free interval was more (P<.001) effective in resolving breakthrough bleeding/spotting than continuing ring use.
  
  
  CONCLUSIONS
  A reduction in bleeding occurred during continuous use with replacement of the transvaginal ring compared with baseline 21/7 use. Continuous vaginal ring use resulted in an acceptable bleeding profile in most patients, reduction in flow, reduction in pelvic pain, and a high continuation rate.
authors.affiliation: Department of Obstetrics and Gynecology, Scott and White Memorial Hospital and Clinic, Texas A&M Health Science Center College of Medicine, Temple, Texas, USA. psulak@swmail.sw.org
authors.forename: Patricia J
authors.initials: PJ
authors.lastname: Sulak
authors.forename: Virginia
authors.initials: V
authors.lastname: Smith
authors.forename: Andrea
authors.initials: A
authors.lastname: Coffee
authors.forename: Iris
authors.initials: I
authors.lastname: Witt
authors.forename: Alicia L
authors.initials: AL
authors.lastname: Kuehl
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Kuehl