***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: A multicentre clinical trial , including 19 centres in 13 countries , assessed the contraceptive efficacy and clinical acceptability of a Silastic 382 vaginal ring releasing 20 micrograms of levonorgestrel for at least 90 days . A total of 1005 women entered the study and 8176.74 woman-months of experience was gathered . The rate of intrauterine pregnancy at one year of use was 3.6 per 100 women ( 95 % confidence interval 2.2 - 5.0 ) , and of ectopic pregnancy , 0.2 % ( one case ) . The principal reasons for discontinuation were menstrual disturbances ( 17.2 % at one year ) , vaginal symptoms ( 6.0 % ) and repeated expulsion of the ring ( 7.1 % ) . The pregnancy rate with this 20 micrograms levonorgestrel-releasing vaginal ring compares favourably with that of a low estrogen combination oral contraceptive tested by WHO and is less than half that of a progestogen-only oral contraceptive in a WHO r and omized study . It is concluded that the WHO intravaginal ring releasing an average of 20 micrograms of levonorgestrel per 24 hours is an effective method of contraception for at least one year of use OBJECTIVE To compare the effects of a pill containing drospirenone with those of a combined contraceptive vaginal ring on the lipid and carbohydrate metabolism and on the surrogate markers of arterial function . SETTING Bologna University School of Medicine . PATIENT(S ) Thirty-seven women with polycystic ovary syndrome ( PCOS ) were r and omly su bmi tted to drospirenone+ethinylestradiol ( group I ; n=19 ) or combined contraceptive vaginal ring ( group II ; n=18 ) therapy . The duration of the study was 6 months . INTERVENTION(S ) The effect of treatments was assessed after 6 months of therapy . MAIN OUTCOME MEASURE(S ) Utero-ovarian ultrasound analysis and color Doppler evaluation of uterine and stromal ovarian arteries . In addition , analysis of brachial artery flow-mediated vasodilatation and 24-hour ambulatory blood pressure monitoring were performed . Fasting blood sample s were drawn for testing biochemical and hormonal parameters and nitrites/nitrates . RESULT ( S ) Both treatments improved hirsutism , hyper and rogenemia , and ultrasound and color Doppler ovarian parameters . Both drospirenone+ethinylestradiol or contraceptive vaginal ring induced a slight but significant increase of diurnal and 24-hour blood pressure . Although both therapies worsened the lipid profile , the oral pill administration was associated with a more evident increase of circulating triglycerides . The 6-month treatment with the vaginal ring significantly improved the area under the curve for glucose , insulin , and C-peptide , whereas the drospirenone+ethinylestradiol pill induced an increase in the insulinogenic index and homeostatic model assessment estimate for insulin resistance values . CONCLUSION ( S ) Vaginal hormonal contraception appears to be preferable to oral ethinylestradiol + drospirenone administration in hyperinsulinemic patients with PCOS Background It is increasingly acknowledged that ‘ acceptability ’ should be considered when design ing , evaluating and implementing healthcare interventions . However , the published literature offers little guidance on how to define or assess acceptability . The purpose of this study was to develop a multi-construct theoretical framework of acceptability of  healthcare interventions  that can be applied to assess prospect i ve ( i.e. anticipated ) and retrospective ( i.e. experienced ) acceptability from the perspective of intervention delivers and recipients . Methods Two methods were used to select the component constructs of acceptability . 1 ) An overview of review s was conducted to identify systematic review s that cl aim to define , theorise or measure acceptability of healthcare interventions . 2 ) Principles of inductive and deductive reasoning were applied to theorise the concept of acceptability and develop a theoretical framework . Steps included ( 1 ) defining acceptability ; ( 2 ) describing its properties and scope and ( 3 ) identifying component constructs and empirical indicators . Results From the 43 review s included in the overview , none explicitly theorised or defined acceptability . Measures used to assess acceptability focused on behaviour ( e.g. dropout rates ) ( 23 review s ) , affect ( i.e. feelings ) ( 5 review s ) , cognition ( i.e. perceptions ) ( 7 review s ) or a combination of these ( 8 review s).From the methods described above we propose a definition : Acceptability is a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate , based on anticipated or experienced cognitive and emotional responses to the intervention . The theoretical framework of acceptability ( TFA ) consists of seven component constructs : affective attitude , burden , perceived effectiveness , ethicality , intervention coherence , opportunity costs , and self-efficacy . Conclusion Despite frequent cl aims that healthcare interventions have assessed acceptability , it is evident that acceptability research could be more robust . The proposed definition of acceptability and the TFA can inform assessment tools and evaluations of the acceptability of new or existing interventions In sub-Saharan Africa , HIV incidence and prevalence remain disproportionately high among women . Vaginal rings ( VRs ) have been formulated for the delivery of antiretroviral-based microbicides , and their favorable safety and tolerability profiles reported in clinical studies . Although the concept of drug release through a VR has existed since 1970 , and VRs have been marketed since 1992 for contraceptive or hormone replacement purpose s , VR use as a microbicide delivery system is a novel application . This is the first study to evaluate VR adherence among African women in the context of its potential use as an HIV prevention method , to examine predictors of adherence , and to describe clinical or context ual reasons for VR removals or nonadherence . This was a r and omized trial of the safety and acceptability of a placebo VR worn for 12 weeks in 170 HIV-negative , African women aged 18–35 in four clinic sites in South Africa and Tanzania . The findings suggest that adherence to VR use in the context of HIV prevention trials in these communities should be high , thereby enabling more accurate assessment of an active microbicide safety and efficacy End-user input is critical to inform development of multi purpose prevention technology ( MPT ) products that prevent HIV and pregnancy . The TRIO Study , conducted in Kenya and South Africa , enrolled 277 HIV-negative women aged 18–30 in a r and omized cross-over study to use each placebo MPT ( daily oral tablets , monthly injections , and monthly vaginal ring ) for one month . At the end of each month , participants rated how much they liked using the product on a 5-point Likert scale ( 5 = liked very much ) . We compared mean ratings using paired t-tests and examined sociodemographic- , attribute- , and behavior-related characteristics associated with ratings using multivariable linear regression and data from in-depth interviews . After use , mean ratings were significantly higher for injections [ 4.3 ( SD = 1.0 ) ] compared with tablets [ 3.0 ( SD = 1.3 ) ] and rings [ 3.3 ( SD = 1.4 ) ] ( p < 0.001 ) ; mean ratings for rings were significantly higher than for tablets ( p = 0.013 ) . Mean ratings of a hypothetical active MPT  increased for all products after the one-month period of use , with the greatest increase for rings , the least familiar product . In multivariable analysis , acceptability of key product attributes ( e.g. , product look ) were associated with a significant increase of ≥ 1 point in the mean rating across all three products ( p ≤ 0.001 ) . Perceived ability to use the product without partner knowledge was associated with a higher mean rating for rings ( b = 0.50 ; p = 0.006 ) . The acceptability of product attributes contributed significantly to the rating of all products , highlighting the value of choice in pregnancy and HIV prevention to accommo date diverse users Abstract Introduction Preventing HIV and unintended pregnancies are key global health priorities . To inform product rollout and to underst and attributes of future multi purpose prevention technologies ( MPT ) associated with preference and use , we evaluated three placebo delivery forms : daily oral tablets , a monthly vaginal ring , and two monthly intramuscular injections in TRIO , a five‐month study among young Kenyan and South African women . Methods HIV‐negative , sexually active , non‐pregnant women aged 18 to 30 were enrolled and r and omized to use each placebo delivery form for one month ( stage 1 ) . Then , participants chose one product to use for two additional months ( stage 2 ) . We assessed safety , product ranking , choice , and use . We examined demographic and behavioural correlates of choice and , reciprocally , unwillingness to use in the future with logistic regression models . Results 277 women enrolled , 249 completed stage 1 and 246 completed stage 2 . Median age was 23 years , 49 % were Kenyan and 51 % were South African . Three participants became pregnant during the study and one participant HIV‐seroconverted . There were 18 product‐related adverse events , six tablets‐related , 11 ring‐related , and one injection‐related . After trying each product , 85 % preferred a TRIO product over condoms . Injections were chosen most ( 64 % , 95 % confidence interval ( CI ) 58 % , 70 % ; p < 0.001 ) , and by more South Africans than Kenyans ( odds ratio ( OR ) 2.01 , 95 % CI : 1.17 , 3.43 ; p = 0.01 ) . There was no significant difference in choosing tablets versus ring ( 21 % , 95 % CI : 16 % , 26 % vs. 15 % , 95 % CI : 11 % , 20 % ; p = 0.11 ) . Tablet and ring adherence , based on direct observations and self‐reports , improved over time . However , participants ’ self‐reported use of tablets did not match objective data from the electronic dose monitoring device . Participants were fully compliant with injections . Conclusion In this population at risk for HIV and pregnancy , all participants agreed to choose and use a placebo MPT delivery form . A majority of participants preferred TRIO products to male condoms , an existing MPT . Injections were most liked and best used , however , they are years away from reaching the clinics . In the meantime , exp and ing the availability of tablets and giving access to rings can begin to fulfill the promise of choice for HIV prevention technologies and inform the development of suitable delivery forms as MPT PURPOSE A crossover study was carried out in 405 couples to compare women 's difficulties with three different devices that could be used to administer a microbicide and to evaluate adherence to use and preference for any one of the devices . METHODS Couples used a single size diaphragm , a vaginal ring or disposable applicators for 1 month each in a r and omly assigned order . RESULTS Few women reported difficulty using the applicators or the ring ; however , almost two-thirds reported difficulty using the diaphragm . Approximately 5 % , 10 % and 40 % of the women and a similar but slightly lower percentage of their partners reported incorrect use of the applicator , vaginal ring and diaphragm , respectively . About half the women preferred the vaginal ring , while around half the men preferred the applicator . CONCLUSION The release of microbicides from a vaginal ring is a lead worth pursuing . The diaphragm is the only one of the three devices that also offers mechanical protection , but it requires greater investment in patient education to ensure adherence to use Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more This open-label , r and omized study compared the pharmacokinetics of ethinylestradiol ( EE ) from the contraceptive vaginal ring NuvaRing  ( 15 microg EE/day ) , the transdermal patch ( 20 microg EE/day ) and a combined oral contraceptive ( COC ) containing 30 microg EE . After 2 - 8 weeks of synchronization by COC treatment , subjects were r and omized to 21 days of treatment with NuvaRing , patch or COC . Analysis of area under the  EE concentration-versus-time curve ( AUC ) during 21 days of treatment showed that exposure to EE in the NuvaRing group was 3.4 times lower than in the patch group ( p < .05 ) and 2.1 times lower than in the pill group ( p < .05 ) . Serum EE levels of subjects showed much lower variation with NuvaRing than with the patch or the COC . Thus , exposure to EE was significantly lower with NuvaRing than with the patch and pill methods , demonstrating that NuvaRing is a low-estrogen-dose contraceptive method that also results in low estrogen exposure OBJECTIVE To assess the efficacy , tolerability , and acceptance of a vaginal ring delivering the equivalent of 50 or 100 microg per day of estradiol ( E2 ) , compared with placebo , for relief of moderate to severe vasomotor symptoms and urogenital symptoms in postmenopausal women . METHODS Women with moderate to severe vasomotor symptoms ( seven or more per day or 56 per week average ) received 13 weeks of treatment with a vaginal ring delivering 50 
    Output:
    
Acceptability improved over time both within studies ( as women gained VR experience and worries diminished ) , and over chronological time ( as the device was popularized ) .
Women expressed preferences for accessible , long-acting , partner-approved methods that prevent both HIV and pregnancy , can be used without partner knowledge , and have no impact on sex and few side effects .
This systematic review suggests that most LMIC women users have a positive view of the VR that increases with familiarity of use ; and , that many would consider the VR an acceptable future delivery device for HIV prevention or other indications