1. Progesterone Vaginal Ring (PVR) Session 1: Characteristics of PVR
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

2. PVR Module Learning Objectives
As a result of actively participating in this training, the learner will be able to:
Describe the progesterone vaginal ring (PVR) to a woman seeking a family planning (FP) method using simple and clear language that she can understand
Explain the criteria for selecting/using the PVR
Demonstrate how to screen women for eligibility to use the PVR
Demonstrate how to counsel a woman about using the PVR as her contraceptive method (including using counseling cards)
Demonstrate how to insert and remove the PVR using a pelvic model (if available)
By the end of this training session, learners will be able to: <click the mouse to advance through the objectives, reading each objective aloud>.
Training Resource Package for Family Planning
Progesterone Vaginal Ring Module Basic Slide Set: Session I

3. Overview of the PVR
The Progesterone Vaginal Ring (PVR) is a safe and highly effective family planning (FP) option for many women in the following situation:
The woman has a baby at least 4 weeks old.
She is breastfeeding the baby at least 4 times per day and plans to continue.
Her menses have not returned.
This module provides an overview of the PVR and provides training on how to counsel clients who are interested in using this method.
Give a general overview of the PVR.
During this training, you will learn how to screen and counsel clients if they are interested in the PVR to space or limit births. You will also learn how to provide follow-up services to clients. You will learn and practice the various tasks during role plays and other activities. You will also be encouraged to think about what it will be like to perform these tasks on the job.
Solicit: Input about whether the planned objectives match learner’s expectations of the training.
Training Resource Package for Family Planning
Progesterone Vaginal Ring Module Basic Slide Set: Session I

4. Rationale for Including the PVR in Family Planning
Expands the range of available family planning methods
No extensive training or complicated new techniques
User-friendly
Easy to explain and counsel
Helps to expand the range of available family planning methods available to breastfeeding women in the first year postpartum.
Requires no extensive training or complicated new techniques for family planning providers to learn.
User-friendly and can be started 4 weeks after birth. One ring can be used for three months without a woman needing to change the ring or change her breastfeeding practices.
Easy to explain and counsel women on, cutting down on health procedures and a patient’s time spent at the health clinic.
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

5. Session Objectives
At the end of this session, the learner will be able to:
Describe the PVR to a woman seeking a family planning method, using simple and clear language that she can understand.
Explain the criteria for selecting/using the PVR.
By the end of this training session, learners will be able to: <click the mouse to advance through the objectives, reading each objective aloud>.
Training Resource Package for Family Planning
Progesterone Vaginal Ring Module Basic Slide Set: Session I

6. What is the progesterone vaginal ring?
Contraceptive method for postpartum women who breastfeed at least 4 times per day
The PVR is a contraceptive that has been designed for use by postpartum women who are breastfeeding. Women may be breastfeeding their babies but may not be exclusively or fully breastfeeding. The PVR is suitable for them especially if they breastfeed at least four times a day.
The ring is made of silicone and is soft, smooth and flexible. It has natural progesterone mixed into the silicone. The PVR is a self-use product and hence a woman should be able to insert it into the vagina and remove it herself. The graphic shows where the ring is inserted.
Ask participants:
What do you know about the Progesterone Vaginal Ring? <allow participants to answer>
What are some qualities of the Progesterone Vaginal Ring that are unique to this method? <allow participants to answer>
Smooth, soft, flexible, silicone ring containing natural progesterone
Easily inserted and removed from the vagina by the woman
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

7. How does it work?
The PVR delivers 10mg of progesterone locally in the vagina, which works in two ways:
Illustration credit: Salim Khalaf/FHI
The PVR delivers 10mg of progesterone locally in the vagina and works in two primary ways. The hormone reaches the circulation system via absorption of the vaginal walls. First, like other progestin-based methods, it suppresses hormones that are responsible for ovulation. It prevents the release of eggs from the ovaries and when no egg is released, there is nothing for the sperm to fertilize. Moreover, in breastfeeding women, the hypothalamic-pituitary system is sensitive to the baby’s suckling of the mother’s breast. and progesterone reinforces the prolactin response to suckling. Thus the combination of suppression of ovulation along with lactational amenorrhea caused by breastfeeding protects a woman against pregnancy.
Second, like other progestin-based methods, the PVR thickens cervical mucus to block sperm. Thicker mucus acts as a barrier making it more difficult for sperm to enter the uterine cavity.
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

8. How does it work? (cont.)
Breastfeeding naturally interferes with the hormones that cause ovulation. PVR’s progesterone reinforces this and suppresses ovulation.
Progesterone extends postpartum amenorrhea: lack of menstruation.
Must continue breastfeeding at least 4 times a day.
Progesterone creates a mucus around the cervix, blocking sperm from reaching egg.
As we talked about in the previous slide, the PVR works in two primary ways. First, by suppressing ovulation and second by thickening cervical mucus. We also know that when the baby suckles at the mother’s breast that it prevents ovulation. The progesterone in the PVR reinforces the prolactin response to suckling. Thus the combination of suppression of ovulation along with lactational amenorrhea caused by breastfeeding protects a woman against pregnancy.
It is because of the effect of suckling that it is important that women breastfeed at least four times a day. Thus the combination of breastfeeding along with the progesterone in the PVR will protect the mother against a pregnancy.
Ask participants: To say in their own words, how the PVR works.
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

9. Who can use it?
Women who are 4 weeks after childbirth and whose menses have not returned
Women who are breastfeeding at least 4 times a day
Baby is less than 1 year old
Women who are not pregnant
No other health conditions
Ask participants:
Women who desire to use the PVR have to satisfy the following conditions. It is important to remember that this is a method for postpartum women who are four weeks postpartum. A woman has to be at least four weeks postpartum to begin to use the PVR so as to reduce the risk of thrombosis in the immediate postpartum period. Furthermore, if she is breastfeeding and due to the high frequency of breastfeeding in the first 4 weeks, she is unlikely to need a contraceptive for further protection against a pregnancy. A woman who meets all the following conditions is a good candidate for the PVR.
Any woman who gave birth over four weeks ago and has not begun menstruating.
She has been breastfeeding her baby and intends to breastfeed her baby as long as she is on the PVR. She needs to breastfeed a minimum of four times a day.
The baby is less than a year old. This is important since the PVR works only in the first year postpartum.
She is not currently pregnant.
And she is healthy and does not have any other health conditions which would preclude her from using the PVR.
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

10. How do you use it?
The woman inserts the ring high in her vaginal canal.
Each ring is effective up to 3 months and she should leave it in the vagina for the entire time.
After 3 months, the woman easily removes the ring and inserts a new one.
She can use this method successively up to 1 year (4 rings in 1 year).
The ring can be left in vagina during intercourse or removed for no more than 2 hours.
The PVR is used by inserting it into the vagina. The user will know that it is in position when she cannot feel the PVR. It is similar to inserting a tampon in countries where tampons are used.
Since each PVR is effective for 3 months, the user needs to keep it inside the vagina for three months. At the end of three months, she should remove the ring and insert a new PVR. Thus, in the first year postpartum, a breastfeeding woman can use four rings in succession with each ring being inside for 3 months. Since the clinical trials were done for a year of use, the current recommendation is for a year of use. However, at the end of the first year, if the woman is still breastfeeding and has not resumed menstruation it is possible that she can still use the PVR.
The user should keep the PVR in all the time. She can keep it in during intercourse and toileting. If however, she wishes to remove it, she should be advised to reinsert within two hours. If there is a gap more than two hours, the effectiveness of the PVR will reduce. Hence, users should be encouraged to keep the PVR inserted at all times and not get in the habit of removal. Keeping it inserted at all times reduces the likelihood of use-related errors such as forgetting to insert on time. If the user forgets to put the PVR within two hours, advise her to use EC or condoms for 24hours after reinsertion or abstain for 24 hours after reinsertion.
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

11. PVR Insertion: Preparation
A client who has chosen an PVR needs to know how to insert it. She needs to know the following:
The client can insert the PVR into her vaginal herself.
Before insertion, she needs to prepare by washing her hands so that they are clean.
Next, she should open the package and remove the PVR from the wrapper.
After she removes the PVR, she should hold it in her fingers--between he thumb and the forefinger and pinch the two sides together. Since the PVR is soft and flexible, she will be easily able to hold the compress the PVR between her fingers.
Wash hands
Open package and take out PVR
Hold the PVR between the thumb and forefinger and press the sides together.

12. PVR Insertion: Insertion Methods
Use your fingers and gently push the ring deep into the vagina—as far as it will go.
Instruct the woman that she can self-insert the PVR. Inserting the PVR should be easy and different women may prefer different ways. Here are three different ways of insertion.
Some women prefer to insert standing up. They can put up their foot on a stool and insert by pushing the ring into their vagina as far as it goes.
Some women find the squatting position easier for insertion. Others prefer to lie down for insertion.
It is important to note that once the ring is properly inserted the woman should not feel the ring. If she does not feel the ring, she will know she has positioned it well. If she feels the ring, she needs to insert it higher.
Conduct Role Play: Use Session Guide for instructions
Laying down
Squatting
The exact position is not important. If inserted correctly, you should not feel it.
Standing

13. PVR Removal
Insert forefinger into the vagina until it has hooked around the ring and gently pull.
The woman needs to know that she can remove the PVR on her own. When she wants to remove the PVR, she inserts her finger into her vagina, hooks it into the ring, and pulls it out. It should come out easily.
Conduct Role Play: Use Session Guide for instructions

14. PVR: Health Benefits Reduced number of unintended pregnancies
Improved birth spacing
Increased breastfeeding rates
This leads to better child nutrition and decreasing maternal and newborn mortality rates.
There are health benefits to both the woman and her baby when she uses the PVR.
Since the PVR is a contraceptive, it protects the mother from unintended pregnancy and hence contributes to reductions in unintended pregnancies. It also works to extend birth intervals.
Since the PVR works as long as the woman is breastfeeding, the baby benefits from being nursed. Babies that are breastfed receive the necessary nutrients they need for healthy development. Breastmilk also provides babies with protected from many common ailments such as diarrhea and pneumonia. Thus babies are offered protection against some common causes of infant mortality.
Thus the use of the PVR benefits both mothers and babies.
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

15. Progesterone Vaginal Ring
Effectiveness of PVR
On this chart of effectiveness, where would you place the PVR?
Implants
Male/Female Sterilization
IUD
Injectable
Oral contraceptives
Progesterone Vaginal Ring
Male condoms
Fertility awareness methods
Diaphragm
Most effective
Ask participants: Where would you put PVR on this list? <After participants respond, click the mouse to reveal the answer>.
The list on this slide categorizes contraceptive methods from most effective to least effective as PERFECTLY used. In this list, diaphragm are the least effective method and the most effective methods are implants.
Use Optional Advanced Slide 2 to review and compare the effectiveness of FP methods during correct and consistent use and common use.
REF:
WHO Dept of RH and Research and JHSPH and CCP K4Health. Family Planning : A Global Handbook for Providers (2011 update) Baltimore and Geneva: CCP and WHO 2011.
(Note: While methods appear to repeat in normal slide view when it is in presenter view it shows the chart without PVR, then with PVR.)
Least effective
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

16. Family Planning Method First Year Pregnancy Rate
Effectiveness of PVR (cont.)
Family Planning Method
First Year Pregnancy Rate
No method 85
Spermicides 16
Diaphragm with spermicide
Standard Days Method 5
Male condoms 2
PVR
1.5
Female Sterilization
0.5
Copper IUD
0.6
Progestin-only pills
0.3
Progestin-only Injectables
0.2
Implants
0.1
Explain that there is another way to look at effectiveness. In this slide we look at effective FP methods as they are correctly (not commonly) used. These data are taken from the latest edition (2018) of the global FP Handbook. They indicate the number of women who would be pregnant in the first year of use out of every 100 users of a particular method. As you can see methods vary in their level of effectiveness. Implants are the most effective and as expected, not using a method at all is the least effective.
Ask participants: What if these same women were using an xxxx? (insert another method used postpartum) How many would become pregnant?
Conduct role plays: See Session Plan and Facilitator’s Guide for instructions on role play scenarios.
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

17. PVR: Normal Possible Side Effects
Mild cramping
Breast tenderness
Changes in bleeding patterns:
Spotting
Irregular bleeding
No menstrual bleeding
Ask the participants: What side effects of the progesterone vaginal ring have you heard about?
Show slides 10 and 11 on side effects. Explain that many women who use the progesterone vaginal ring experience side effects.
The PVR like other progestin-based methods has some possible side-effects. Most women are not likely to be menstruating because they are more likely to be in lactational amenorrhea. Others might have spotting or irregular bleeding.
Some women may have mild cramping and some others might have breast tenderness.
Adapted from the Population Council’s Balanced Counseling Strategy Plus
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

18. PVR: Rare Possible Side Effects
Rare, but return to clinic if experience:
Severe pain
Unusual, bad smelling discharge
Genital lesions
Ask the participants: What side effects of the progesterone vaginal ring have you heard about?
Show slides 10 and 11 on side effects. Explain that many women who use the progesterone vaginal ring experience side effects.
It is very rare for women using the PVR to have other serious side-effects. Most side-effects tend to be minor as we just saw on the previous slide. In very rate cases, women may have severe pain or bad-smelling discharge or genital lesions. If any of these were to happen, providers should counsel the woman to come to the clinic for a check-up.
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

19. PVR: Advantages and Disadvantages
Advantages Disadvantages
Safe for mother and baby
98.5% effective
Easy to use
No effect on breastfeeding
Fertility returns without delay when removed
Safe for a woman living with HIV/AIDS, even if she takes antiretroviral medicines
Partner may be able to feel the ring
Only for up to one year
Removal for over two hours reduces efficacy
Provides no protection from sexually transmitted infections, including HIV
Has some side effects
Ask trainees to brainstorm first a list of positive characteristics (advantages) and then negative characteristics of PVR.
Write these suggested characteristics on a flip chart. Then show the slide of PVR characteristics and compare them to the list generated through brainstorming.
In this slide we summarize the main advantages and disadvantages that will help women decide if they want to use the PVR.
The advantages are that it is a safe and effective method. It is safe for both the mother and baby. Use of the PVR does not affect the mother’s ability to breastfeed—it does not alter the volume of milk she produces. Furthermore, since it is a self-use product, the woman can use or not use the PVR as per her preference. It is safe for women who are HIV positive and are taking ARV medicines. Fertility returns once she stops using the PVR.
On the other hand, there are some disadvantages. Since the PVR is a vaginal product, some men may feel the ring during intercourse and if the woman wants to keep her contraceptive use secret, it may not be appropriate. Women who want to use a contraceptive for periods longer than a year will have to switch to a different method after 1 year. It does not protect against HIV and other STIs. Side-effects exist but these are minor.
Ask participants: How is the Progesterone Vaginal Ring different from other hormonal methods? <allow participants to answer>
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

20. Key Points for Providers and Clients
Important to remember:
Can be stopped at any time without a provider’s help.
Removing the ring for any period of time may reduce efficacy. 
If removed, reinsert within 2 hours to maintain efficacy
If more than 2 hours, reinsert immediately and use EC or condoms for 24 hours after reinsertion, or abstain for 24 hours after reinsertion.
Seek another method if not breastfeeding at least 4 times/day.
Use condoms to protect against sexually transmitted infections, including HIV/AIDS.
Give an overview of the key points about the progesterone vaginal ring, using the points on the slide.
Both providers and clients should remember that the PVR is a self-use method. Therefore, clients can control how they want to use the ring. They can remove it at any time on their own.
The PVR will be effective as long as use-instructions are followed. The PVR has to be inserted at all times for it to be effective. If for any reason, the user wants to remove it, the ring should be replaced within 2 hours. If the PVR has been left out for more than 2 hours, the user needs to reinsert it and use an additional method of contraception such as condoms or EC for the next 24 hours if she wants to have sex. Alternatively, she can abstain from sex for 24 hours after she has reinserted the ring.
The user needs to switch to a different contraceptive if she continues to desire pregnancy protection and she plans to breastfeed her baby less. As the baby begins to eat solid foods there could be a time when the user will not be able to nurse at least 4 times a day.
Finally, the PVR will not provide protection against HIV and other STIs.
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I

21. Key Points for Clients 4 3 2 1 It’s as easy as…
Breast feed 4 times a day 3
Wear each ring for 3 months
Before showing the slide: Ask participants: “What do you think are the most important messages to give clients about PVR?”
Allow participants to answer; then show the slide and add to the participants’ responses as needed. (See Session Plan.)
Here is an easy way to remember—it is as easy as 1, 2, 3, 4. Read out the points on the slide and link the number to the action.
Reinsert ring within 2 hours if removed 2 1
Use until your child’s 1st birthday, then talk to provider to seek a new method
Training Resource Package for Family Planning Progesterone Vaginal Ring Module Basic Slide Set: Session I