What are the contraindications for NuvaRing (etonogestrel and ethinyl estradiol)

Contraindications for NuvaRing (Etonogestrel and Ethinyl Estradiol)

NuvaRing is contraindicated in women with a history of thromboembolic disorders, cardiovascular disease, uncontrolled hypertension, migraine with aura, breast cancer, liver disease, or undiagnosed abnormal genital bleeding.

Major Contraindications

NuvaRing contains both estrogen (ethinyl estradiol) and progestin (etonogestrel), classifying it as a combined hormonal contraceptive. As such, it shares contraindications with other combined hormonal methods 1, 2:

Cardiovascular and Thrombotic Conditions

• Current or history of deep vein thrombosis or pulmonary embolism
• Cerebrovascular disease or coronary artery disease
• Thrombogenic valvular or rhythm heart diseases
• Hypercoagulopathies
• Complicated valvular heart disease
• Migraine with aura or focal neurological symptoms
• Age ≥35 years who smoke (especially heavy smokers)
• Multiple cardiovascular risk factors

Hypertension

• Uncontrolled hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg)
• Hypertension with vascular disease

Cancer

• Current or history of breast cancer
• Other estrogen- or progestin-sensitive cancers
• Carcinoma of the endometrium

Liver Conditions

• Acute or chronic hepatic dysfunction
• Hepatic tumors (benign or malignant)
• Severe cirrhosis
• Active viral hepatitis
• Cholestatic jaundice of pregnancy or jaundice with previous hormonal contraceptive use

Other Contraindications

• Pregnancy (Category X)
• Undiagnosed abnormal genital bleeding
• Hypersensitivity to any component of NuvaRing
• Renal dysfunction or adrenal insufficiency
• Age ≥35 years with diabetes and vascular complications

Special Considerations

Drug Interactions

NuvaRing's effectiveness may be reduced when used with 1, 2:

• Anticonvulsants (carbamazepine, phenobarbital, phenytoin)
• Antimicrobials (rifampin, rifabutin, griseofulvin)
• HIV protease inhibitors
• St. John's wort
• Other enzyme inducers

Hereditary Angioedema

Women with hereditary angioedema caused by C1 inhibitor deficiency may experience exacerbation of symptoms with NuvaRing use 1.

Hepatitis C Treatment

For women on certain hepatitis C treatments, NuvaRing may be contraindicated due to drug interactions 1.

Risk of Venous Thromboembolism

The risk of venous thromboembolism (VTE) is a significant concern with NuvaRing use 1, 3, 4:

• Baseline VTE risk in non-users: 1 per 10,000 woman-years
• Risk with combined hormonal contraceptives: 3-4 per 10,000 woman-years
• This risk is substantially lower than the VTE risk during pregnancy (10-20 per 10,000 woman-years)

Clinical Implications

Pretreatment Assessment

Before prescribing NuvaRing, clinicians should:

• Obtain a thorough personal and family history of thrombotic events
• Measure blood pressure
• Screen for migraine with aura
• Assess for liver disease
• Consider age and smoking status

Patient Counseling

Patients should be informed about:

• Warning signs of thromboembolism (leg pain/swelling, chest pain, severe headache)
• The need to remove NuvaRing before major surgery or prolonged immobilization
• The importance of disclosing NuvaRing use before surgical procedures 4

Alternative Options

For women with contraindications to combined hormonal methods like NuvaRing, alternative contraceptive options include:

• Progestin-only methods (pills, implants, injections)
• Intrauterine devices (hormonal or non-hormonal)
• Barrier methods

Conclusion

While NuvaRing is an effective contraceptive option with 91-95% typical-use effectiveness 2, 5, careful patient selection is essential to minimize risks. The contraindications are similar to those of other combined hormonal contraceptives, with particular emphasis on conditions that increase thrombotic risk.