Should a 31-year-old female, using Nuvaring (etonogestrel/releasing intrauterine system), discontinue use for 1 week to induce menses after experiencing breakthrough bleeding and light spotting of dark brown discharge for 2 weeks following initiation of a continuous cycle with a new ring replacement after 3 weeks?

From the Guidelines

For a 31-year-old female experiencing breakthrough bleeding while using NuvaRing continuously, she does not need to remove the ring for a week to trigger menses. She can continue with the continuous cycling as planned. Breakthrough bleeding is common when starting hormonal contraception or when switching to continuous use, especially during the first few months. This spotting typically resolves on its own as the body adjusts to the hormones 1. If the bleeding is bothersome, she could remove the ring for 4 days (not a full week) to allow for a controlled withdrawal bleed, then insert a new ring. However, this is optional and based on preference, not medical necessity. The dark brown discharge indicates old blood, which is normal. If continuous heavy bleeding occurs or if she experiences severe pain, unusual discharge, or other concerning symptoms, she should consult her healthcare provider. The hormones in NuvaRing (etonogestrel/ethinyl estradiol) work by maintaining a steady state that prevents ovulation and thins the endometrial lining, which can initially cause some irregular bleeding until the body adapts. It's also important to consider underlying gynecological problems, such as interactions with other medications, an STD, pregnancy, or new pathologic uterine conditions, and treat or refer for care if necessary 1. In general, NSAIDs for short-term treatment (5–7 days) or hormonal treatment (if medically eligible) with low-dose COCs or estrogen for short-term treatment (10–20 days) can be considered if the bleeding persists and the woman finds it unacceptable 1. Ultimately, the decision to continue or change the contraceptive method should be based on the woman's preferences and medical eligibility.

From the Research

Breakthrough Bleeding and Nuvaring Use

• Breakthrough bleeding and light spotting of dark brown discharge are common side effects experienced by some women when using Nuvaring, especially during the initial stages of use 2, 3.
• A study published in 2002 found that irregular bleeding occurred in only 4.4% of cycles during Nuvaring use, and consisted mainly of spotting 3.
• Another study published in 2005 reported that the incidence of irregular bleeding with Nuvaring was between 2.6-6.4% 2.

Discontinuing Nuvaring Use to Induce Menses

• There is no evidence to suggest that discontinuing Nuvaring use for 1 week is necessary or recommended to induce menses after experiencing breakthrough bleeding and light spotting 2, 4, 3, 5.
• In fact, a study published in 2002 found that cycle control with Nuvaring was excellent, with withdrawal bleeding occurring in 98.8% of cycles during the 1-week ring-free period 3.
• The manufacturer's instructions for Nuvaring recommend continuous use for 21 days, followed by a 7-day ring-free period, and do not suggest discontinuing use to induce menses.

Managing Breakthrough Bleeding with Nuvaring

• Women experiencing breakthrough bleeding and light spotting while using Nuvaring may want to consider speaking with their healthcare provider about their symptoms and treatment options 2, 4, 3, 5.
• A study published in 2004 found that reductions in menstrual pain and the length of the menstrual period were reported during Nuvaring use, and that more than 90% of women were satisfied or very satisfied with the ring 5.