How do I use the vaginal ring (NuvaRing) (etonogestrel and ethinyl estradiol) to manage menstrual symptoms as a woman of reproductive age?

How to Use the Vaginal Ring (NuvaRing)

Insert the NuvaRing vaginally for 3 consecutive weeks, then remove it for 1 week to allow withdrawal bleeding, and insert a new ring after the 7-day ring-free interval even if bleeding has not stopped. 1, 2

Standard Insertion and Removal Schedule

• Insert the ring on day 1-5 of your menstrual cycle and leave it in place continuously for 21 days (3 weeks). 3
• Remove the ring after 3 weeks and discard it—each ring is designed for single-cycle use only. 4, 5
• Wait exactly 7 days (1 week) ring-free to allow withdrawal bleeding, then insert a new ring to start the next cycle. 1, 2
• Insert the new ring after 7 days even if bleeding has not ceased—do not wait for bleeding to stop before starting the next ring. 1, 2

During Use

• The ring stays in place during intercourse and most male partners do not notice it or are not bothered by its presence. 1
• The ring can be temporarily removed for up to 3 hours if desired (though this is not typically recommended), but must be reinserted within this timeframe to maintain contraceptive effectiveness. 1, 2
• If the ring is accidentally expelled, rinse it with cool water and reinsert immediately if it has been out for less than 3 hours. 1

What to Do If You Miss Timing

If Ring Removal is Delayed or Insertion is Late by Less Than 48 Hours:

• Insert or reinsert the ring as soon as possible. 1
• Keep the ring in until your scheduled ring removal day. 1
• No backup contraception is needed. 1
• Emergency contraception is not usually needed but can be considered if the delay occurred in the last week of the previous cycle. 1

If Ring Removal is Delayed or Insertion is Late by 48 Hours or More:

• Insert the ring as soon as possible and keep it in until the scheduled removal day. 1
• Use backup contraception (condoms) or avoid intercourse until the ring has been worn for 7 consecutive days. 1
• If the delay occurred during the third week of ring use: Skip the hormone-free week entirely by finishing the third week and starting a new ring immediately. 1
• Emergency contraception should be considered if the delay occurred within the first week of ring use and unprotected intercourse occurred in the previous 5 days. 1

Extended/Continuous Use Option

The ring can be used continuously for up to 35 days by replacing it once every calendar month, eliminating the hormone-free interval. 1, 2

• This extended regimen is particularly useful for managing menstrual symptoms, dysmenorrhea, or conditions exacerbated by hormonal cycling. 6, 7
• If you experience more than 5 consecutive days of unscheduled bleeding during continuous use, remove the ring for 3-4 days (but not during the first 21 days of use and not more than once per month). 1
• The longer duration of continuous hormones may result in more unscheduled bleeding days initially, but this typically decreases with continued use. 1

Expected Side Effects

Common Side Effects (First 3-6 Months):

• Unscheduled spotting or bleeding is common during the first 3-6 months and generally decreases with continued use—this is not harmful. 1, 2
• Vaginal discharge, vaginal discomfort, and device-related events such as expulsion may occur. 1, 2
• Headaches, nausea, and breast tenderness are possible but occur at lower rates than with oral contraceptives due to steady hormone levels. 1, 8

When to Seek Medical Attention:

• Contact your provider immediately if you experience severe headaches, chest pain, severe leg pain, or shortness of breath—these may indicate serious complications. 7
• If unscheduled bleeding persists beyond 6 months and is bothersome, discuss treatment options with your provider. 1

Contraceptive Effectiveness

• The typical-use failure rate is 9%, comparable to birth control pills, with a perfect-use failure rate of 0.3%. 1, 2, 4
• The ring does not protect against sexually transmitted infections—use condoms for dual protection. 2
• Effectiveness may be reduced in women weighing more than 198 pounds. 7

Key Advantages for Menstrual Symptom Management

• The ring provides the simplest regimen among combined hormonal contraceptives, requiring only monthly attention rather than daily pill-taking. 1, 6
• Continuous or extended use can reduce menstrual frequency, which is beneficial for managing dysmenorrhea, endometriosis, or other cyclically-exacerbated conditions. 6, 7
• The steady hormone delivery avoids daily fluctuations in serum levels, potentially improving symptom control. 4