How soon after delivery can Nuvaring (etonogestrel and ethinyl estradiol) be used postpartum?

When to Start NuvaRing After Delivery

NuvaRing (etonogestrel/ethinyl estradiol vaginal ring) should not be used until at least 21 days postpartum in non-breastfeeding women and should be avoided until at least 6 weeks postpartum in breastfeeding women due to increased risk of venous thromboembolism. 1, 2

Timing Guidelines Based on Breastfeeding Status

For Breastfeeding Women:

• Wait at least 6 weeks postpartum before starting NuvaRing 1, 2
• Rationale:
  • Combined hormonal contraceptives during the first 3 weeks after delivery are contraindicated (U.S. MEC 4) due to increased thromboembolism risk 1
  • Generally should not be used during the fourth week postpartum (U.S. MEC 3) due to potential effects on breastfeeding performance 1
  • Women with additional risk factors for venous thromboembolism generally should not use combined hormonal contraceptives 4-6 weeks after delivery (U.S. MEC 3) 1
  • Combined hormonal methods can reduce milk production 3

For Non-Breastfeeding Women:

• Wait at least 21 days postpartum before starting NuvaRing 1, 2, 4
• Rationale:
  • Combined hormonal contraceptives are contraindicated during the first 3 weeks after delivery (U.S. MEC 4) due to increased thromboembolism risk 1
  • Women with additional risk factors for venous thromboembolism generally should not use combined hormonal contraceptives 3-6 weeks after delivery (U.S. MEC 3) 1
  • The risk of postpartum thromboembolism decreases after the third postpartum week 4

Need for Back-up Contraception

When starting NuvaRing postpartum:

• If starting ≥21 days postpartum and menstrual cycles have not returned:

  • Use additional contraceptive protection for the next 7 days 1

• If menstrual cycles have returned and it has been >5 days since menstrual bleeding started:

  • Use additional contraceptive protection for the next 7 days 1

Risk Assessment Before Starting NuvaRing

Before initiating NuvaRing postpartum, evaluate:

• Personal or family history of thrombotic/thromboembolic disorders 4
• Additional risk factors for VTE (smoking, obesity) 4
• Blood pressure (required before initiating hormonal contraceptives) 2

Important Considerations and Cautions

• The postpartum period carries an inherently elevated risk of thromboembolism, which is highest immediately after delivery 4
• NuvaRing contains both estrogen and progestin, placing it in the combined hormonal contraceptive category 1
• For women who want earlier contraception postpartum, consider progestin-only methods which can be started immediately after delivery 2, 3
• NuvaRing is contraindicated in women over 35 who smoke due to increased cardiovascular risk 4

Alternative Options During the Waiting Period

While waiting to start NuvaRing:

• Progestin-only pills can be started immediately postpartum 2
• Implants can be inserted at any time postpartum 2
• Lactational amenorrhea method (LAM) is effective for up to 6 months if exclusively breastfeeding, amenorrheic, and baby is less than 6 months old 2
• Barrier methods like condoms can provide temporary protection 5

Following these guidelines will help minimize the risk of thromboembolism while ensuring effective contraception during the postpartum period.