Can the Annovera (segesterone acetate and ethinyl estradiol) vaginal contraceptive ring cause chronic yeast infections?

Can Annovera Cause Chronic Yeast Infections?

Yes, Annovera can increase the risk of recurrent vaginal yeast infections, with vulvovaginal mycotic infections/vaginal candidiasis occurring in 14.5% of users in clinical trials, making it one of the most common adverse effects of this contraceptive ring. 1

Clinical Evidence from Annovera Trials

In the pivotal clinical trials involving 2,308 women using the final manufactured Annovera ring:

• Vulvovaginal mycotic infection/vaginal candidiasis occurred in 14.5% of users across 21,590 cycles of exposure 1
• This was the third most common adverse reaction reported, after headache (38.6%) and nausea/vomiting (25.0%)
• Approximately 1.3% of women discontinued Annovera specifically due to vaginal discharge or vulvovaginal mycotic infections 1

The safety profile study confirmed that vaginal discharge and vulvovaginal mycotic infections were among the top reported adverse events, with 242 women (10%) experiencing these symptoms 2.

Why Vaginal Rings May Increase Yeast Risk

The mechanism involves multiple factors:

• Hormonal effects: Combined hormonal contraceptives (CHCs) like Annovera alter the vaginal environment through estrogen and progestin effects on vaginal epithelium and glycogen content
• Physical presence: Research demonstrates that yeasts can directly adhere to vaginal ring materials. In vitro studies show that Candida albicans, C. tropicalis, and other yeast species are capable of adhering to contraceptive vaginal rings, which could facilitate colonization and infection 3
• Intrauterine device association: Studies comparing contraceptive methods found that both hormonal and non-hormonal intrauterine device users had increased vaginal colonization with Candida compared to other contraceptive methods 4

Clinical Management Approach

If a patient develops recurrent yeast infections while using Annovera:

1. Confirm the diagnosis objectively - Don't rely solely on symptoms, as less than half of patients treated for VVC actually have it 5. Use:

   • Wet mount microscopy with 10% KOH preparation
   • Vaginal culture (gold standard)
   • PCR testing (sensitivity 90.9%, specificity 94.1% for Candida group) 5

2. Treat acute episodes appropriately:

   • First-line: Topical azole antifungals for 7 days (clotrimazole, miconazole, terconazole) 5
   • Alternative: Oral fluconazole 150 mg single dose 5
   • Important caveat: If using miconazole, recommend cream formulation rather than suppositories - research shows miconazole suppositories increase systemic absorption of both segesterone acetate and ethinyl estradiol from Annovera (EE levels increased by 67% with single-dose suppository), while cream does not affect hormone levels 6

3. For recurrent VVC (≥4 episodes/year):

   • Obtain vaginal cultures to identify non-albicans species (present in 10-20% of recurrent cases) 7
   • Consider longer initial therapy (7-14 days topical azole or fluconazole 150 mg repeated 3 days later) 7
   • Maintenance therapy for 6 months may be needed 7

4. Consider contraceptive method change if infections persist despite treatment:

   • Progestin-only pills (POPs) or subcutaneous implants are associated with lower Candida carriage rates compared to intrauterine contraception 4
   • Combined oral contraceptives maintain normal vaginal bacterial flora similar to non-contraceptive users 4

Important Caveats

• 10-20% of women normally harbor Candida species in the vagina without symptoms - asymptomatic colonization should not be treated 8
• The ring should remain in place during yeast infection treatment unless removal is medically indicated
• Avoid miconazole suppositories during Annovera use due to drug-drug interaction; use cream or oral fluconazole instead 6
• Document whether infections are truly recurrent or represent treatment failure of the same episode

Bottom line: While Annovera does increase yeast infection risk compared to no contraception, most cases respond well to standard antifungal therapy. However, if a patient develops truly chronic/recurrent infections (≥4 per year) that persist despite appropriate treatment, switching to a progestin-only method may be warranted.