What is the workup for a NuvaRing (etonogestrel and ethinyl estradiol) refill?

Workup for NuvaRing Refill

For a NuvaRing refill, no routine workup is required—simply assess blood pressure and ask about any new contraindications or concerning symptoms since the last visit. 1

Essential Components of the Refill Visit

Blood Pressure Measurement

• Measure blood pressure at each refill visit to monitor for hypertension, which is a key safety parameter for combined hormonal contraceptives 1

Screening Questions (No Physical Exam Required)

Ask specifically about new or worsening conditions that would contraindicate continued use:

• Thrombotic events: Any history of blood clots in legs or lungs, stroke, or heart attack 1
• Breast concerns: New breast lumps or diagnosis of breast cancer 1
• Liver disease: Jaundice, hepatitis, or other liver problems 1
• Undiagnosed vaginal bleeding: New abnormal bleeding patterns that are unexplained 1
• Pregnancy: Missed periods or pregnancy symptoms 1
• Warning symptoms: Severe headaches, chest pain, severe leg pain, or shortness of breath 2

Assess Satisfaction and Side Effects

• Ask about vaginal symptoms (discharge, discomfort, ring expulsion) which are the most common device-related issues 3, 4
• Inquire about breakthrough bleeding, headaches, nausea, or breast tenderness 2
• If breakthrough bleeding persists beyond 3-6 months and is bothersome, consider a 3-4 day hormone-free interval (but not during the first 21 days of use and not more than once per month) 3

Adherence Assessment

• Confirm the patient is using the ring correctly: 3 weeks in, 1 week out, then new ring 3
• If the patient frequently forgets to replace the ring or has compliance issues, discuss switching to a less user-dependent method like an IUD or implant 5

What You Do NOT Need

• No pelvic exam required for routine refills 1
• No laboratory tests (no pregnancy test if no missed periods, no lipid panels, no thrombophilia screening) 1
• No cervical cytology unless due per routine screening guidelines unrelated to contraception 1
• No routine follow-up visits are mandated—patients should return only if they experience problems or wish to change methods 2

Common Pitfalls to Avoid

• Do not require unnecessary pelvic exams, which create barriers to contraceptive access 1
• Do not order routine labs in asymptomatic patients—this is not evidence-based and delays care 1
• Remember that the ring can be safely used throughout reproductive years with no maximum duration limit 2
• Be aware that the ring may be less effective in women weighing more than 198 pounds 1

Extended Use Option

• The ring can be used continuously for up to 35 days (replacing monthly) to reduce menstrual frequency, which may benefit patients with dysmenorrhea, endometriosis, or adherence challenges 3, 2
• No backup contraception is needed when transitioning to continuous use if the ring has been used correctly 2