What are the instructions for using Nuvaring (etonogestrel/released levonorgestrel) for a female patient of reproductive age with no known contraindications?

NuvaRing Instructions for Use

Insert NuvaRing vaginally on any day from day 1 to day 5 of your menstrual cycle, leave it in place continuously for 3 weeks (21 days), then remove it for exactly 1 week (7 days) before inserting a new ring. 1, 2, 3

Insertion and Removal

• Compress the ring between your thumb and index finger and insert it into the vagina, pushing it up as far as comfortable—the exact position is not critical for effectiveness. 2, 3
• The ring remains in place for 21 consecutive days, during which it releases 15 μg ethinyl estradiol and 120 μg etonogestrel daily. 2, 4
• After 3 weeks, remove the ring on the same day of the week it was inserted (e.g., if inserted on a Monday, remove on Monday 3 weeks later). 2, 3
• Discard the used ring after removal—each ring is designed for single-cycle use only. 3, 4
• After a 7-day ring-free interval, insert a new ring on the same day of the week as the previous insertion, even if bleeding has not stopped. 2, 3

Backup Contraception Requirements

• If inserted within the first 5 days of menstrual bleeding, no backup contraception is needed. 1
• If inserted after day 5 of your cycle, use backup contraception (condoms) or abstain from intercourse for 7 consecutive days. 1

Managing Ring Problems

If the Ring Slips Out (Expulsion)

• If out for less than 3 hours: Rinse with cool-to-lukewarm water and reinsert immediately—no backup contraception needed. 2, 5
• If out for more than 3 hours during weeks 1-2: Reinsert as soon as possible and use backup contraception for 7 days. 2
• If out for more than 3 hours during week 3: Either insert a new ring immediately (skipping the ring-free week) or have your ring-free week now, then insert a new ring after 7 days. 2

If You Forget to Remove the Ring

• If left in for up to 4 weeks total (1 week extra): Remove it, take the 7-day ring-free break, then insert a new ring—contraceptive protection is maintained. 2
• If left in for more than 4 weeks: Remove it immediately, use backup contraception for 7 days, and consider emergency contraception if unprotected intercourse occurred. 2

If You Forget to Insert a New Ring After the Ring-Free Week

• Insert the new ring as soon as you remember and use backup contraception for 7 days. 2
• Consider emergency contraception if unprotected intercourse occurred during the extended ring-free interval. 1, 6

Effectiveness

• NuvaRing has a typical-use failure rate of 9% and perfect-use failure rate of 0.3%, comparable to combined oral contraceptives and the contraceptive patch. 1
• In clinical trials, the Pearl Index was 0.65 (95% CI 0.24-1.41), with three of six pregnancies occurring in women who violated the prescribed regimen. 2
• Compliance rates are high at 90.8% of cycles, significantly better than daily pill-taking. 2

Common Side Effects and Monitoring

• Most frequently reported side effects include: headache (6.6%), vaginal discharge/leukorrhea (5.3%), and vaginitis (5.0%). 2, 5
• Estrogen-related side effects are less common than with oral contraceptives: nausea (2.8%) and breast tenderness (1.9%). 2
• Device-related events such as ring expulsion, foreign body sensation, or coital problems occur in approximately 2.6% of users. 2
• Blood pressure should be monitored during routine follow-up visits. 7

Absolute Contraindications

Do not use NuvaRing if you have: 1, 6

• History of or current deep vein thrombosis or pulmonary embolism
• History of stroke or heart attack
• Uncontrolled hypertension
• Breast cancer or other estrogen/progestin-sensitive cancers
• Active liver disease or liver tumors
• Unexplained vaginal bleeding
• Known or suspected pregnancy
• Age >35 years and current smoking
• Migraine headaches with aura (especially if >35 years old)
• Known hypercoagulable conditions

Special Situations

Vomiting or Severe Diarrhea

• Unlike oral contraceptives, NuvaRing effectiveness is not compromised by vomiting or diarrhea since absorption occurs through the vaginal epithelium, not the gastrointestinal tract. 7, 4

Postpartum Use

• Can be initiated ≥21 days postpartum in non-breastfeeding women without need for backup contraception if amenorrheic. 1
• If breastfeeding, combined hormonal contraceptives like NuvaRing should generally be avoided in the first month postpartum, though can be used ≥1 month postpartum with caution. 1

Drug Interactions

• Be aware of interactions with anticonvulsants, certain antibiotics (rifampin), St. John's wort, and some HIV protease inhibitors, which may decrease contraceptive effectiveness. 1
• Use backup contraception when taking medications that may interfere with hormonal contraception. 1

Important Clinical Pearls

• The ring does not need to be removed during intercourse, though it can be removed for up to 3 hours if desired. 5
• Cycle control is excellent with NuvaRing, with 97-99% of cycles having regular withdrawal bleeding lasting 4.7-5.3 days. 3
• The low, continuous hormone delivery results in lower systemic hormone levels compared to oral contraceptives, potentially reducing side effects. 8, 4
• NuvaRing does not protect against sexually transmitted infections—use condoms for STI protection. 1