NuvaRing Contraindications
NuvaRing (etonogestrel/ethinyl estradiol vaginal ring) shares the same contraindications as combined oral contraceptives, as it contains ethinyl estradiol and carries comparable thromboembolic risks.
Absolute Contraindications
The following conditions absolutely contraindicate NuvaRing use 1:
Cardiovascular and Thromboembolic Conditions
- Active or history of deep vein thrombosis (DVT) or pulmonary embolism (PE) 1
- Active or history of arterial thromboembolic disease (stroke or myocardial infarction) 1
- Cerebrovascular disease or coronary artery disease 1
- Thrombogenic valvular or thrombogenic rhythm diseases 1
- Known hypercoagulopathies 1
- Uncontrolled hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg) 1
- Smoking if ≥35 years of age 1
Neurological Conditions
- Headaches with focal neurologic symptoms 1
- Migraine headaches with or without aura if ≥35 years of age 1
Hepatic Conditions
- Hepatic dysfunction or hepatic disease 1
- Hepatic adenomas or carcinomas (benign or malignant hepatic tumors) 1
- Cholestatic jaundice of pregnancy or jaundice with previous pill use 1
Malignancies
Other Conditions
- Pregnancy 1
- Undiagnosed abnormal genital/uterine bleeding 1
- Renal dysfunction 1
- Adrenal insufficiency 1
- Anaphylactic reaction or angioedema to components 1
- Surgery with prolonged immobilization 1
Critical Clinical Considerations
Thromboembolic Risk Profile
NuvaRing carries at least equivalent thromboembolic risk to combined oral contraceptives 1, 2. Research demonstrates that NuvaRing has 2.5 times increased relative risk of thrombotic stroke compared to nonuse 3. Case series show approximately half of NuvaRing-associated strokes are venous (cerebral venous sinus thrombosis) and half are arterial, with stroke occurring as early as 2 weeks after initiation 3.
Special Populations
Women with hereditary angioedema (HAE-C1-INH): Combined parenteral estrogen-progestin formulations including vaginal rings contain as much ethinyl estradiol as oral contraceptives and have similar hepatic side effects, with limited evidence of tolerance in HAE patients 1.
Women with cardiovascular disease: The vaginal ring is inappropriate for patients with complex valvular disease, despite containing lower doses of ethinyl estradiol (15 μg) 1.
Common Pitfall
Patients may fail to disclose NuvaRing use during preoperative screening because they do not consider it a "medication" since it is self-inserted and removed 4. Always specifically ask about vaginal contraceptive rings when assessing thrombotic risk before surgery or when evaluating thromboembolic events 4.
Drug Interactions
For women requiring hepatitis C treatment with sofosbuvir/velpatasvir/voxilaprevir, concomitant use with ethinyl estradiol-containing contraception (including NuvaRing) is contraindicated due to risk of ALT elevations 1.