Can I use NuvaRing (etonogestrel/releasing vaginal ring) with a pessary?

Using NuvaRing with a Pessary

NuvaRing can be safely used with a pessary, as there are no contraindications or interactions between these two vaginal devices when used simultaneously. The contraceptive efficacy of NuvaRing should remain unaffected by the presence of a pessary.

Compatibility of NuvaRing and Pessary

NuvaRing is a contraceptive vaginal ring that releases a combination of estrogen (15 μg ethinyl estradiol) and progestin (120 μg etonogestrel) daily 1. It works through the same mechanism as combined oral contraceptives but provides a simpler regimen with steady hormone delivery.

When considering the compatibility with a pessary:

• NuvaRing is designed to be positioned in the upper vagina, surrounding the cervix 2
• Pessaries are typically placed to support pelvic structures and generally sit lower in the vaginal canal
• MRI studies have shown that NuvaRing naturally positions itself around the cervix in the upper vagina, away from the introitus, especially after ambulation 2

Practical Considerations

When using both devices together:

1. Insertion order: Insert the pessary first, followed by the NuvaRing
2. Positioning: Ensure the NuvaRing is placed high in the vagina, surrounding the cervix
3. Check placement: After insertion of both devices, verify that:
   • The pessary remains properly positioned
   • The NuvaRing is not displaced by the pessary

Efficacy and Safety

NuvaRing has excellent contraceptive efficacy with a Pearl Index of 0.65 (typical use) 3, comparable to combined oral contraceptives with a typical use failure rate of 9% 1. This efficacy should be maintained when used with a pessary, provided both devices remain properly positioned.

Key points about NuvaRing:

• It follows the standard regimen of 3 weeks in, 1 week out 1
• It provides steady hormone levels compared to oral contraceptives 4
• It has excellent cycle control 4

Potential Concerns and Solutions

1. Expulsion risk:

   • NuvaRing expulsion is reported in 4-20% of women 4
   • The presence of a pessary might theoretically increase this risk
   • Solution: Check NuvaRing placement regularly, especially after initial insertion

2. Vaginal symptoms:

   • Both devices can cause vaginal discharge or discomfort
   • Monitor for increased vaginal symptoms when using both devices
   • If irritation occurs, consult healthcare provider for alternatives

3. Removal considerations:

   • When removing the pessary for cleaning, be careful not to accidentally remove the NuvaRing
   • If the NuvaRing is accidentally removed, it can be rinsed with cool to lukewarm water and reinserted within 3 hours

Important Cautions

• If the NuvaRing is out for more than 3 hours, backup contraception should be used for 7 days
• The standard contraindications for combined hormonal contraceptives apply to NuvaRing, including history of venous thromboembolism 5
• Women with hereditary angioedema should be aware that NuvaRing, like other estrogen-containing contraceptives, may increase attack frequency 1

NuvaRing offers a convenient contraceptive option with 9% typical use failure rate 1, and its use should not be compromised by the concurrent use of a pessary when both are properly positioned and monitored.