NuvaRing (Etonogestrel/Ethinyl Estradiol) - Vaginal

What Is NuvaRing?

NuvaRing  (etonogestrel/ethinyl estradiol vaginal ring) is a form of hormonal birth control available in the form of a vaginal ring. The two primary ingredients, estrogen (ethinyl estradiol) and progestin (etonogestrel) are the two female sex hormones present.

The vaginal ring is inserted into the vagina (intravaginally) to prevent pregnancy in individuals of childbearing age. NuvaRing works in three ways:

• By preventing ovulation. Ovulation is the release of eggs from the ovaries.
• By changing the lining of the uterus, or womb, to prevent pregnancy from developing
• By changing the mucus at the cervix (the opening of the uterus) to prevent sperm from entering

What Is NuvaRing Used For?

The FDA has approved NuvaRing to prevent pregnancy in people of childbearing age.

While contraceptive vaginal rings are a very effective method of birth control, they do not prevent the spread of human immunodeficiency virus (HIV; the virus that causes acquired immunodeficiency syndrome, AIDS) and other sexually transmitted infections (STIs).

How to Use NuvaRing

If you are prescribed NuvaRing:

Read the prescription label, information leaflet, and medication guide that comes with your prescription. Consult your healthcare provider if you have any questions. Use NuvaRing exactly as directed by your healthcare provider. NuvaRing is inserted into the vagina. It is not worn outside the body.

To insert NuvaRing, you can start in one of three positions - standing with one leg up, squatting, or lying down. Compress the ring and insert it into the vagina. Or, you can use the applicator to insert NuvaRing. To remove, hook your index finger under the front rim, or grasp the rim between your index finger and middle finger and pull it out. Place the used ring in the foil pouch and discard it in the trash, out of reach of children and pets.

You must wear NuvaRing 24 hours a day for 21 days (three full weeks) to prevent pregnancy. It does not prevent pregnancy if you only wear it during intercourse. Do not wear more than one vaginal ring at a time.

For seven days after inserting NuvaRing for the first time, you may need to use a form of backup birth control, such as external condoms (not a diaphragm or internal condom). Ask your healthcare provider how long you need to use backup birth control. Remove the vaginal ring after 21 days. Do not leave it for longer than three weeks.

Then, wait seven full days before inserting a new ring. During this one-week break, you will usually get your period. Call your healthcare provider if you have difficulty removing the ring, or if you get off your schedule. Notify your healthcare provider if you have breakthrough bleeding.

If you are scheduled for surgery or will be on bed rest for a period of time, tell your healthcare provider. You may need to stop using NuvaRing for a short time.

Ask your healthcare provider if you have any questions or concerns about NuvaRing.

Storage and Disposal

NuvaRing can be stored for up to four months at room temperature. Keep NuvaRing out of direct light, heat, and moisture. Do not store it in the bathroom. Check the expiration date before using NuvaRing. Do not use an expired NuvaRing.

Each NuvaRing is packaged individually in a reclosable pouch. After removing a ring from the vagina, put it in the pouch and discard it in the garbage. Do not flush NuvaRing. Keep NuvaRing out of reach of children and pets.

Off-Label Uses

Occasionally, NuvaRing will be used off-label for indications that are not FDA-approved.

Healthcare providers may prescribe NuvaRing to individuals:

• To treat severe acne (when external acne medications do not work)
• To treat amenorrhea (the absence of a monthly period)
• For abnormal bleeding or heavy periods
• For excess hair growth on the face, chest, and back
• To treat polycystic ovary syndrome (a hormone imbalance caused by the ovaries)
• To treat endometriosis

What Are the Side Effects of NuvaRing?

This is not a complete list of side effects, and others may occur. A healthcare provider can advise you on side effects. If you experience other effects, contact your pharmacist or a healthcare provider. You may report side effects to the FDA at fda.gov/medwatch or 1-800-FDA-1088.

Like other medications, NuvaRing can cause side effects. Tell your healthcare provider about any side effects you experience while taking this medication.

Common Side Effects

Common side effects include:

• Irregular bleeding
• Nausea and vomiting
• Breast tenderness
• Headache
• Stomach pain and bloating
• Swelling
• Weight gain or loss
• Vaginal inflammation
• Mood swings/depression
• Acne
• Brown patches on the face
• Changes in sex drive
• Increased hypertension (high blood pressure)
• Increased cholesterol
• Glucose intolerance (higher than normal blood sugar)
• Contact lens discomfort
• Vaginal yeast infection/itching
• Foreign body sensation
• Expulsion (the NuvaRing may accidentally come out)

Severe Side Effects

NuvaRing has a black box warning. A black box warning is the strongest warning required by the FDA.

Smoking cigarettes increases the risk of serious cardiovascular (heart) events, such as heart attack and stroke in individuals who use combination hormonal birth control. NuvaRing is a combination of hormonal birth control. A combination of hormonal birth control contains estrogen (NuvaRing contains ethinyl estradiol) and progestin (NuvaRing contains etonogestrel).

The risk is higher with age, especially in those 35 years or older. The risk also increases with the number of cigarettes smoked. Because of this risk, combination birth control, including NuvaRing, should not be used in people who are over 35 years old and smoke.

Call your healthcare provider right away if you have serious side effects. Call 911 if your symptoms feel life-threatening or if you think you’re having a medical emergency. Serious side effects and their symptoms can include the following:

• Hypersensitivity reaction or anaphylaxis: Symptoms can include rash, hives, swelling around the lips, tongue, and face, difficulty breathing, and require emergency medical attention. 
• Blood clots: Be aware of sudden vision loss, chest pain, shortness of breath, coughing up blood, pain, or warmth in the leg(s).
• Heart attack: Be aware of chest pain or pressure, pain spreading to the jaw or shoulder, nausea, and sweating.
• Stroke: Be alert to sudden numbness or weakness (especially on one side of the body), sudden severe headache, slurred speech, or vision or balance problems.
• High blood pressure: Blood pressure should be monitored and communicated to the healthcare provider. Your healthcare provider will tell you how often to check your blood pressure.
• Liver problems: Symptoms may include appetite loss, upper stomach pain, tiredness, dark urine, and yellowing of the skin or whites of the eyes (a potential sign of jaundice)f
• Depression: Symptoms may include mood changes and/or thoughts of hurting yourself
  
• Eye lesions: Report any vision changes or eye pain to your healthcare provider.
• Toxic shock syndrome: Be alert to fever, body aches, skin rash, vomiting, diarrhea, and dizziness.
• Possible increased risk of cervical or breast cancer: Ask your healthcare provider about your risk and steps you can take for monitoring, such as regular gynecologic exams and mammograms.

Long-Term Side Effects

Individuals who use NuvaRing should discuss possible long-term health risks with their healthcare provider.

With combination birth control, the risk of breast cancer is slightly increased. One study noted that there were limited breast cancer cases in people who used birth control methods such as the vaginal ring, but that there was not enough evidence to make an association specifically between the vaginal ring and breast cancer.

Combination birth control may cause an increased risk of clotting. In studies, some cases of clotting occurred in people who used NuvaRing, but the association is not clear.

Other long-term side effects can occur, such as eye, liver, or gallbladder problems.

You should discuss the risks versus benefits of using NuvaRing with your healthcare provider, especially since every person has a unique medical history that may affect their risk of long-term complications.

Dosage: How Much NuvaRing Should I Use?

Modifications

Users should be aware of the following before beginning NuvaRing:

Individuals with liver problems: People with any type of liver tumor should not use NuvaRing. People with any type of liver problem should consult their healthcare provider for medical advice.

Individuals with kidney problems: People with any type of kidney problem should consult their healthcare provider for medical advice.

Postmenopausal people: NuvaRing has not been studied in postmenopausal people and should not be used.

Pregnant people: NuvaRing is intended to prevent pregnancy and should not be used on pregnant people.

Nursing people: People who are breastfeeding should consult their healthcare provider regarding how long after childbirth they can start using NuvaRing.

People over 65: NuvaRing has not been reviewed in postmenopausal people and is not used in this population.

Children: The safety and efficacy of NuvaRing have been established in people of reproductive age. Efficacy is expected to be the same for postpubertal adolescents under 18 and users 18 years and older.

Missed Dose

If your NuvaRing falls out, rinse the ring with warm water. Then, reinsert the ring into the vagina. If your ring is lost or broken, insert a new ring and stay on the same schedule.

If a ring has been out of the vagina for more than three hours:

During week 1 or 2: Reinsert the ring as soon as you remember. Use a barrier method of birth control (external condom with spermicide) until the ring has been used for seven continuous days.

During week 3: Discard the ring. Then, you can either:

• Insert a new ring immediately, which starts a new three-week use period. You may have breakthrough bleeding.
• Insert a new ring no less than seven days from the time the previous ring was removed or expelled. You may have bleeding during that time. You should only choose this option if the ring was used continuously for at least seven days before it was inadvertently removed or expelled. You will need to use a barrier method of birth control until the new ring has been in place for at least seven days.

If you're not sure how long NuvaRing was out of the vagina, take a pregnancy test before inserting a new ring.

If you are not sure what to do, consult your healthcare provider or pharmacist for instructions.

Overdose: What Happens If I Take Too Much NuvaRing?

The prescribing information shows that there have been no reports of serious problems from combination birth control overdose. Overdose may cause withdrawal bleeding and nausea. If the vaginal ring breaks, it will not cause an overdose.

Precautions

What Are Reasons I Shouldn't Use NuvaRing?

NuvaRing is not appropriate for everyone. You should not take this medication if you are allergic to ethinyl estradiol, etonogestrel, or any of the inactive ingredients in NuvaRing.

Other people who should not use NuvaRing include:

• Pregnant people
• Individuals who are less than four weeks postpartum (and not breastfeeding)
• Individuals who are less than weeks postpartum (and breastfeeding)
• Individuals with cancer or a history of cancer that is estrogen-dependent or progestin-dependent
• People with breast cancer or a history of breast cancer
• People with a liver tumor or active liver disease
• People with a history of cholestatic jaundice (a liver disease associated with blocked bile flow), that is associated with oral birth control or pregnancy
• People with blood clots, a history of blood clots, or blood that forms clots too easily
• People who are having major surgery where will be immobilized (not able to move about) for a period of time
• People over 35 years old who smoke, or individuals of any age who smoke heavily
• Individuals with heart or blood vessel disease
• Individuals whose systolic blood pressure (the top number) is over 160 millimeters of mercury or diastolic blood pressure (the bottom number) is over 100 millimeters of mercury
• People with blood vessel conditions, or diabetes with blood vessel conditions
• Individuals with migraine headaches
• People with undiagnosed vaginal bleeding
• Individuals with positive or unknown lupus antibody

NuvaRing may be prescribed with caution in some people, only if the healthcare provider determines it is safe. This includes:

• People with liver or kidney problems
• People with high cholesterol
• People with diabetes
• People with inflammatory bowel disease
• People with gallbladder disease
• People who are sensitive to fluid retention
• People with a history of depression
• People who have obesity
• People with hereditary angioedema (a rare genetic disorder that causes swelling)

What Other Medications May Interact With NuvaRing?

Tell your healthcare provider about all of the medicines you take, including prescription and over-the-counter (OTC) medicines, and vitamins or supplements. While taking NuvaRing, do not start any new medications without approval from your healthcare provider.

Examples of drugs and supplements that can decrease the effectiveness of NuvaRing (making breakthrough bleeding or an unintended pregnancy more likely):

• Dilantin (phenytoin)
• Rifampin
• St. John's Wort
• Tegretol (carbamazepine)
• Topamax (topiramate)

Talk to your healthcare provider about possible drug interactions. If you take a medication that may interact with NuvaRing, you may need a backup method of birth control, such as an external condom and spermicide. Certain barrier methods, like the internal condom or diaphragm, may not be able to be positioned correctly due to the NuvaRing.

Some drugs may increase levels of NuvaRing's hormones in the body. Examples of these drugs include antifungals such as Diflucan (fluconazole), Nizoral (ketoconazole), and Sporanox (itraconazole). This can happen with grapefruit, too. Avoid grapefruit and grapefruit juice while using NuvaRing.

Certain antiviral drugs can also interact with NuvaRing. If you have HIV or the hepatitis C virus (HCV), consult your healthcare provider about drug interactions.

NuvaRing can interact with Lamictal (lamotrigine), with the effect of reducing seizure control. A dosage adjustment may be needed.

Individuals who take thyroid replacement, such as Synthroid (levothyroxine), may need higher doses of levothyroxine.

This is not a full list of drug interactions. Other drug interactions may occur with NuvaRing. Consult your healthcare provider for a complete list of drug interactions.

What Medications Are Similar?

There are various methods of birth control. Some just prevent pregnancy, while others can also help prevent sexually transmitted infections. Discuss the best method of birth control with your healthcare provider, who can help determine which method would be best for you, considering your medical conditions, other drugs you take, and your lifestyle.

For example, some prefer to take a pill by mouth every day, while others have a hard time remembering to take it and prefer a longer-acting form of birth control, such as an injection.

NuvaRing is a type of hormonal birth control. It is a vaginal ring that is inserted into the vagina to prevent pregnancy. Another vaginal ring is called Annovera.

Other types of hormonal birth control (that are used for pregnancy prevention and do not protect against sexually transmitted infections) include:

• Birth control pills are about 91% effective with typical use, and around 99% effective with perfect use (taking the pill at the same time every day and never skipping a dose). Some contain estrogen and progestin and are known as combined oral contraceptives, such as Lo Loestrin Fe. Others only contain progestin and are known as the "mini-pill," such as Micronor or Heather.
• Birth control patches are worn on the skin. They are also about 91% effective.
• The birth control shot, called Depo-Provera, is about 94% effective. It is given every three months by a healthcare provider. The Depo-subQ Provera 104 is another form of birth control shot that people can administer themselves, once trained.
• An intrauterine device (IUD) such as Mirena or Kyleena, is 99% effective and is a small device that is inserted into the uterus by your healthcare provider to provide contraception for several years (the length of time depends on which IUD is used). There is also a hormone-free IUD called Paragard.
• A birth control implant, Nexplanon, is a very small rod inserted under the skin of the upper arm. It is about 99% effective and provides contraception for up to three years.

There are other types of birth control methods too, such as external or internal condoms, and diaphragms, among others. Talk to your healthcare provider about the best method of birth control and/or sexually transmitted infection prevention.

This list is a list of drugs also prescribed for birth control. It is NOT a list of drugs recommended to take with NuvaRing. Ask your pharmacist or a healthcare provider if you have questions.

How Can I Stay Healthy While Taking NuvaRing?

Smoking, while using hormonal birth control, can greatly increase the risk of blood clots, stroke, or heart attack. Do not smoke while using NuvaRing. If you need help stopping smoking, talk to your healthcare provider about various options.

While we often think of drug interactions, NuvaRing has a food interaction to be aware of. Grapefruit can interact with NuvaRing. While using NuvaRing, avoid grapefruit, grapefruit juices, or any mixed fruit drinks that contain grapefruit juice. Let your healthcare provider know of any medications, OTC, and herbal supplements that you take.

NuvaRing does not protect you against sexually transmitted diseases such as HIV and AIDS. A condom is the best protection against these diseases. You can always consult your healthcare provider for more information about preventing pregnancy and sexually transmitted infections.