Annovera (Segesterone Acetate and Ethinyl Estradiol) – Vaginal

What Is Annovera?

Annovera (segesterone acetate and ethinyl estradiol) is a vaginal ring system used for birth control, or contraception.

Known as a combined hormonal contraceptive (CHC), Annovera contains both the hormones segesterone acetate and ethinyl estradiol. These are synthetic forms of progestin and estrogen, respectively, which are hormones found naturally in your body that regulate your menstrual cycle.

Annovera is an opaque and white flexible ring made of silicone material, like rubber. It is inserted into the vagina. As a prescription product, Annovera is only available once your healthcare provider writes you an order for it. You will get the prescription filled at a pharmacy rather than purchasing it over the counter (OTC) from a drugstore or grocery store.

What Is Annovera Used For?

Annovera is a CHC that contains synthetic forms of both progestin and estrogen. Each day Annovera is in the vagina, it releases an appropriate amount of hormones to prevent pregnancy—similar to what you would get from taking birth control pills.

You can use one Annovera ring for 13 cycles of 21 days in and seven days out.

How to Use Annovera

You can insert the Annovera ring in whichever position makes you feel the most comfortable.

Wash and dry your hands. Before inserting and after removing the ring from the package, wash it with mild soap and lukewarm water, rinse, and pat dry with a cloth or paper towel. To insert, pinch the ring between your thumb and forefinger, and place it as far back into the vagina as possible. If you can feel the ring, it may not be inserted far enough.

Leave Annovera in for 21 days and then remove it for seven days. During these seven days off, you will most likely have a withdrawal bleed for some of the time. A withdrawal bleed can feel similar to menstrual bleeding, but it is not the same as a period.

How you start using Annovera depends on whether you were using any birth control before and what type you were using.

How to Start Annovera If You Have Not Been Using Hormonal Contraception

If you were not previously using any hormonal birth control, including if you have had a copper intrauterine device (IUD) removed, you can insert Annovera between days two and five of your period. In this case, you do not need to use any backup birth control during sex.

If you weren’t on any hormonal birth control but your periods are irregular, or you just want to start Annovera right away, that’s OK.

Make sure to use an extra form of birth control during sex for the first seven days after inserting Annovera if you:

• Insert the ring more than five days from your last period
• Are not sure when you had your last period

A backup form of birth control can include a condom, diaphragm, or cervical cap.

How to Start Annovera After Using Combined Hormonal Contraception

You may be switching to Annovera from another CHC, like birth control pills containing estrogen and progestin. In this case, you can change to Annovera on any day of your cycle as long as you have been taking your pills consistently and don’t suspect that you may be pregnant. You do not need to use a backup method of birth control.

Keep in mind that no more than seven days should go by between stopping your old birth control method and starting Annovera. If seven or more days pass, use your backup birth control for another seven days after inserting Annovera. Check with your healthcare provider if you are unsure whether your birth control pills are combined, meaning they contain both estrogen and progestin.

How to Start Annovera After Using Progestin-Only Contraception

If you’re switching to Annovera from any progestin-only method of birth control, be aware that you will need to use an additional barrier method of birth control during sex for the first seven days after inserting Annovera.

If you were previously taking a progestin-only pill like Camila, Jolivette, Micronor, or Nora-BE, insert Annovera when you would have taken your next pill. If you previously used a progestin-only injection like Depo-Provera, start Annovera at the time of your next scheduled injection.

If you’re starting Annovera after using a progestin-only implant such as Nexplanon, or an IUD like Skyla, Kyleena, Liletta, or Mirena, insert Annovera at the time your implant or IUD gets removed.

How to Start Annovera After an Abortion or Miscarriage

If you start Annovera within the first five days after a first-trimester abortion or miscarriage, you do not need to use a backup method of birth control. If more than five days have passed, follow the instructions above for starting Annovera if you have not been using hormonal contraception.

If your abortion or miscarriage happened later than your first trimester, wait at least four weeks to start Annovera due to an increased risk of blood clots.

How to Start Annovera After Having a Baby

Starting Annovera too soon after having a baby can also increase your risk of developing a blood clot. Wait at least four weeks after giving birth to start.

Additionally, you’ll only want to start Annovera this soon if you choose not to breastfeed. Using Annovera can reduce how much milk you produce and expose your baby to hormones, so use a different method of birth control until you wean the baby from the breast.

Finally, when you start Annovera after having a baby, use a backup method of birth control for the first seven days.

Storage

After removing the ring, wash it with mild soap and pat dry with a clean cloth or paper towel. Then, store it in its case. After seven days, wash and dry it again before inserting.

Off-Label Uses

Reasons for using hormonal contraception can extend beyond pregnancy prevention.

For example, hormonal birth control can help control irregular menstrual cycles, treat extremely heavy or painful periods, and also improve hormonal acne.

Additionally, Annovera is approved by the Food and Drug Administration (FDA) only to be kept inserted for 21 days, left out for seven days, and repeated for a year. However, some healthcare providers may prescribe it off-label for continuous use. Continuous use means it is never taken out or only taken out every few months. In these cases, your healthcare provider will need to write you a new Annovera prescription before a year is up.

What Are the Side Effects of Annovera?

This is not a complete list of side effects and others may occur. A medical professional can advise you on side effects. If you experience other effects, contact your pharmacist or a medical professional. You may report side effects to the FDA at www.fda.gov/medwatch or 800-FDA-1088.

Common Side Effects

The following are some of the more common side effects of using Annovera. If you notice these side effects and think they are severe or do not go away, you should notify your healthcare provider:

• Headache or migraine
• Nausea and vomiting
• Fungal (yeast) infection in the vaginal area
• Lower or upper abdominal pain
• Painful periods, typically involving cramps (dysmenorrhea)
• Vaginal discharge
• Urinary tract infection (UTI)
• Breast tenderness, pain. or discomfort
• Irregular vaginal bleeding, including metrorrhagia (bleeding from the uterus)
• Diarrhea
• Genital pruritus, or itching, around the vagina or vulva

Severe Side Effects

Annovera, and all combined (estrogen-containing) hormonal contraceptives, carry the risk of blood clots and other vascular or heart-related events.

Estrogen and its synthetic forms like ethinyl estradiol, found in Annovera, can make your blood form clots more easily. This can lead to an increased risk of heart attack, stroke, and blood clots. The risk is higher in smokers, women older than 35, or those with high blood pressure, high cholesterol, diabetes, or obesity.

Potential severe side effects of Annovera include:

• Venous thromboembolism (VTE): This blood clot forms in your veins and can block blood flow to your heart. VTEs can be life-threatening if not treated. Symptoms include leg pain or swelling, reddish discoloration, and skin that feels warm to the touch.
• Myocardial infarction (MI), also known as a heart attack: Symptoms of an MI may include chest discomfort like pressure, squeezing, fullness, or pain. Discomfort in one or both arms, the back, neck, jaw, or stomach can also be a sign. 
• Stroke: A stroke is another medical emergency that occurs when blood flow to your brain gets cut off or interrupted. Symptoms include drooping in the face, arm weakness, and difficulty speaking or walking.

Other serious side effects include:

• Toxic shock syndrome (TSS)
• Liver problems
• High blood pressure
• Gallbladder problems
• Changes in cholesterol and triglyceride levels in the blood
• Depression
• Possible cervical cancer

Call 911 if your symptoms feel life-threatening or if you think you’re having a medical emergency.

Long-Term Side Effects

The vascular risks like heart attack, stroke, and blood clots that come with taking CHCs like Annovera gradually disappear after stopping the drug.

There are many misconceptions about the effect of hormonal contraceptives on fertility, or the ability to get pregnant. While hormonal birth control lowers your fertility while you take it (so you don’t get pregnant), your fertility will return to normal when and if you decide to stop taking birth control.

Dosage: How Much Annovera Should I Take?

Modifications

Annovera is indicated for females of reproductive age, meaning individuals who have started having periods. It can be used safely and effectively in females younger than 18 who have started having periods, but not before. Annovera has not been studied and should not be used in females who have reached menopause.

Based on clinical trials, around two to four out of every 100 women using Annovera may still get pregnant, making it about 97% effective at preventing pregnancy. The chances are very low, but it’s still possible to get pregnant using Annovera. If you become pregnant, you should remove the Annovera ring. However, you don’t need to worry about the fetus, as studies have not found a higher risk of birth defects after exposure to hormonal contraceptives during early pregnancy.

Missed Dose

Set reminders on your phone or write down your schedule to avoid getting off track on inserting and removing Annovera. Even an app available for iOS and Android can help you keep track of your schedule.

If Annovera falls out for some reason, like during sex or when removing a tampon, wash it with mild soap, pat dry with a clean cloth or paper towel, and reinsert it.

The following scenarios will require you to use a backup method of birth control until Annovera has been inserted in your vagina for seven days straight without falling out:

• If Annovera falls out and stays out of your vagina for longer than two hours straight during your 21-day “on” cycle
• If the time Annovera is out of your vagina adds up to two hours in the same 21-day cycle. For example, if it’s left out one day for an hour, and then again for an hour and a half on another day of the same cycle
• If Annovera is left out for longer than seven days during your "off" cycle

Overdose: What Happens If I Take Too Much Annovera?

It is impossible to overdose on Annovera if you use it as directed. The ring releases only a small amount of hormones each day.

If you leave Annovera inserted for more than 21 days, it should be removed for seven days and then reinserted for 21 to continue your regular schedule. That is unless you are using Annovera continuously. Talk to your healthcare provider if you are interested in a continuous method.

Precautions

What Are Reasons I Shouldn’t Use Annovera?

You should not take Annovera if you have any of the following:

• A high risk of blood clots, such as if you are a smoker over age 35, or have a current or history of blood clots, uncontrolled high blood pressure, or have diabetes and are over age 35
• Migraine headaches with aura (which causes a change in your vision), or are over age 35 with any migraine headaches
• Current or history of breast cancer
• Liver diseases such as tumors, hepatitis, or cirrhosis (scarring of the liver that is usually permanent)
• Abnormal uterine bleeding (menorrhagia) that hasn’t been addressed by a healthcare provider

What Other Medications Interact With Annovera?

There are a few drugs that can interrupt how well Annovera works. Some drugs may not work as well because of Annovera.

Certain medications may decrease your exposure to Annovera and reduce Annovera’s efficacy. These drugs include:

• Barbiturates, like phenobarbital and secobarbital
• Medications used to prevent seizures (anticonvulsants) such as Tegretol (carbamazepine), Trileptal (oxcarbazepine), and Lamictal (lamotrigine), among others 
• Griseofulvin: A drug used to treat fungal infections
• Rifadin, Rimactane (rifampin): An antibiotic used to treat tuberculosis
• Products containing Saint-John’s-wort

Drugs that may not work as well because of Annovera include:

• Lamictal (lamotrigine)
• Thyroid hormone or corticosteroid replacement therapy, such as Synthroid (levothyroxine) or prednisone, among others
• Painkillers like Tylenol (acetaminophen) and morphine
• Restoril (temazepam): A drug used for anxiety and sleep

Finally, you should not use oil-based vaginal suppositories with Annovera due to unpredictable effects on the ring system and the potential for higher exposure to the hormones. Water-based products should be used instead for vaginal conditions that need to be treated.

The same goes for lubricants used during sex. Water-based lubes do not affect Annovera, but avoid oil-based products (including silicone-based).

What Medications Are Similar to Annovera?

Many types of hormonal and nonhormonal birth control options exist. There are progestin-only and combined hormonal options, which contain estrogen and progestin.

CHC pills are similar to Annovera in that they also use two forms of hormones to prevent pregnancy. They are available in several different formulations and brand names.

The NuvaRing (ethinyl estradiol and etonogestrel) is a vaginal ring product similar to Annovera. It is also available generically as the EluRyng. Unlike Annovera, this ring does not get reused each cycle. You use a new NuvaRing each cycle and throw the old one away. Both NuvaRing and Annovera contain ethinyl estradiol, but the NuvaRing has the progestin etonogestrel instead of segesterone acetate found in Annovera.

The above is not a list of drugs recommended to take with Annovera. You should not take these drugs together. Ask your pharmacist or a healthcare practitioner if you have questions.

How Can I Stay Healthy While Taking Annovera?

Deciding which birth control option is the best fit for you is a very personal choice. It can take some trial and error to find the right one for you based on convenience, side effects, and effectiveness. Whichever form you decide on, the most important thing is that you fully understand how it works and how to use it properly.

Don’t be embarrassed to ask your healthcare provider about your birth control options. Any question you have has been asked of them many times before. You have the power to make your own choices regarding your sexual and reproductive health.