What is NuvaRing (etonogestrel and ethinyl estradiol), a vaginal ring used for birth control?

What is NuvaRing?

NuvaRing is a flexible, combined hormonal contraceptive vaginal ring that releases 15 μg of ethinyl estradiol and 120 μg of etonogestrel daily to prevent pregnancy through ovulation suppression. 1

Mechanism and Composition

NuvaRing is made of ethylene-vinyl-acetate copolymer and works by inhibiting ovulation while also creating physiologic conditions unfavorable for pregnancy. 2, 3 The ring provides continuous, low-dose hormone delivery directly through the vaginal mucosa, offering an alternative to daily oral contraceptives. 4

How to Use NuvaRing

The standard regimen involves inserting one ring vaginally for 3 consecutive weeks, then removing it for 1 week to allow withdrawal bleeding, followed by insertion of a new ring after the 7-day ring-free interval—even if bleeding has not ceased. 1, 5

Key Usage Details:

• Insertion timing: Insert on any day from day 1 to day 5 of the menstrual cycle 3
• Removal during intercourse: The ring can be temporarily removed for up to 3 hours if desired, though this is not typically recommended 5, 1
• Most male partners do not notice the ring during intercourse 1
• The ring is easy to insert and remove by the woman herself 6

Extended Use Option

The ring contains sufficient medication to be used for up to 35 days, allowing for extended or continuous use by replacing it once every calendar month. 5, 1 This extended regimen is particularly beneficial for patients with dysmenorrhea, endometriosis, anemia, Von Willebrand disease, or conditions that worsen cyclically such as migraine without aura, epilepsy, and irritable bowel syndrome. 7 Women using continuous cycles who experience more than 5 consecutive days of bleeding can remove the ring for 4 days to reduce overall bleeding days. 5

Effectiveness

NuvaRing has a typical-use failure rate of 9% and a perfect-use failure rate of 0.3%, comparable to combined oral contraceptives. 1 The Pearl Index from clinical trials ranges from 0.65 to 1.18, demonstrating high contraceptive efficacy. 8, 3 The ring may be less effective in women weighing more than 198 pounds. 9

Side Effects

Common Side Effects:

• Vaginal symptoms: discharge (5.3%), vaginitis (5.0%), and discomfort 5, 2
• Systemic effects: headache (6.6%), nausea (2.8%), breast tenderness (1.9%) 8
• Device-related events: expulsion, foreign body sensation, or coital problems (2.6% discontinuation rate) 8
• Breakthrough bleeding or spotting is the most common adverse effect with extended use 5, 7

Notably, NuvaRing has a lower incidence of estrogen-related side effects like nausea compared to oral contraceptives. 8 In clinical trials, 41% of women experienced no adverse events during 1 year of use. 8

Contraindications and Risks

NuvaRing has the same eligibility criteria, risks, and contraindications as combined oral contraceptives. 1 It is contraindicated in women with:

• High risk of arterial or venous thrombotic diseases 1, 4
• History of breast cancer or other estrogen/progesterone-sensitive cancers 4
• Severe liver disease 4
• Undiagnosed abnormal uterine bleeding 1

Studies have yielded inconsistent results about VTE risk with the ring compared to low-dose combined oral contraceptives. 5 Blood pressure should be measured at each refill visit to monitor for hypertension. 9

Important Clinical Considerations

• The ring does not protect against sexually transmitted infections or HIV; condoms should be recommended for dual protection 1
• The ring can be safely used throughout reproductive years with no maximum duration limit 9
• Compliance is high, with regimen criteria fulfilled in 90.8% of cycles 8
• User satisfaction is excellent: more than 90% of women report being satisfied or very satisfied, and 97% would recommend it to others 6
• The ring has bone neutrality, though studies have not included adolescents younger than 18 years 5

Monitoring at Refill Visits

At each refill visit, assess for:

• Blood pressure measurement 9
• New or worsening contraindications (thrombotic events, breast concerns, liver disease, pregnancy) 9
• Warning symptoms (severe headaches, chest pain, severe leg pain, shortness of breath) 9
• Vaginal symptoms, breakthrough bleeding, headaches, nausea, or breast tenderness 9
• Correct usage pattern (3 weeks in, 1 week out) 9

If patients frequently forget to replace the ring, discuss switching to less user-dependent methods like an IUD or implant. 9