What is it used for?

• Preventing an unwanted pregnancy (contraception).

Key facts

• NuvaRing can be a good contraceptive option if you don't want to think about contraception every day or every time you have sex.
• NuvaRing is most often prescribed for young women who don't have any major health issues. It's not suitable for women who have an increased risk of getting a blood clot, including women over 35 who smoke.
• NuvaRing is more than 99% effective when used correctly. It's not affected by vomiting or diarrhoea, but can be affected by some medicines.
• NuvaRing won't protect you against sexually transmitted infections; you'll still need to use condoms for that.
• The most common side effects include vaginal discharge or infections, headaches, feeling sick, breast tenderness and mood changes.
• Breakthrough bleeding, spotting and missed periods can be common in the first few months. See your doctor if this persists. If you don't have a period for two consecutive months, do a pregnancy test before inserting the next month's ring.
• Blood clots are a rare but serious side effect of NuvaRing. 

How does NuvaRing work?

• NuvaRing contains two active ingredients, ethinylestradiol and etonogestrel. These are synthetic versions of the naturally occurring female sex hormones, oestrogen and progesterone. The ring releases these hormones continuously into the vagina, from where they are absorbed into the bloodstream.
• The hormones in NuvaRing are similar to the hormones used in contraceptive pills and work in the same way. They over-ride your natural menstrual cycle and work mainly by stopping your ovaries from releasing an egg each month (ovulation). They also increase the thickness of the natural mucus at the neck of the womb, making it more difficult for sperm to cross from the vagina into the womb, as well as thinning the womb lining (endometrium), making it more difficult for any successfully fertilised eggs to implant there.
• You insert one ring and leave it in place for three weeks, then remove it and have a week break before inserting a new ring. During your ring-free week the levels of hormones in your blood fall and you'll usually get a withdrawal bleed that's like your period.

Who shouldn't use NuvaRing?

NuvaRing is not suitable for all women. You shouldn't use it if you:

• are over 35 and you smoke, or you stopped smoking less than a year ago
• are very overweight (BMI more than 35)
• have ever had a blood clot in your leg (deep vein thrombosis) or lungs (pulmonary embolism)
• have ever had a heart attack, angina, stroke or mini-stroke
• have very high blood pressure (hypertension) or vascular disease
• have heart valve disease or an irregular heartbeat called atrial fibrillation
• have a blood disorder that increases your risk of blood clots, eg antiphospholipid syndrome or factor V Leiden
• have severe diabetes with complications affecting the eyes, kidneys or nerves
• suffer from migraines with aura
• have breast cancer now or have had it in the last five years
• have liver disease, eg liver cancer, severe cirrhosis
• have gallbladder disease
• have ever had jaundice, itching, a hearing disorder called otosclerosis, or a rash called pemphigoid gestationis, when pregnant or when taking the pill before
• have a rare metabolic disorder called porphyria.

Your doctor may need to weigh up the risks and benefits of using NuvaRing if you have various other conditions, including those below. If two or more of these apply your doctor will usually recommend that you use a different type of contraception:

• You are 35 years or older.
• You smoke.
• You are overweight.
• You have high cholesterol levels.
• You have high blood pressure (hypertension).
• You have diabetes.
• Your parent, brother or sister had a heart attack, stroke or blood clot in the leg (deep vein thrombosis) or lungs (pulmonary embolism) before the age of 45.
• You use a wheelchair.
• You have a long-term condition called systemic lupus erythematosus (SLE).
• You have Crohn's disease or ulcerative colitis.
• You have a history of migraines.
• You have an undiagnosed breast lump or gene mutations that are associated with an increased risk of breast cancer, eg BRCA1.

Can I use it if I'm breastfeeding?

• NuvaRing is not the preferred method of contraception for women who are breastfeeding, because the oestrogen in it can reduce the amount of breast milk you produce. If you do decide you want to use it you shouldn't start until at least six weeks after the birth, when breastfeeding is fully established.

How do I use NuvaRing?

• To insert NuvaRing, squeeze the ring between your thumb and forefinger and push it into your vagina until it feels comfortable. The exact position of the ring in your vagina is not critical.
• Leave the NuvaRing in your vagina for three weeks. Check regularly that it's still there, particularly after having sex. After three weeks remove the ring, then have a one week ring-free break. During this week you'll usually get a withdrawal bleed that's similar to your normal period. Insert a new ring after seven days, even if you haven't stopped bleeding. 
• You'll still be protected in your ring-free week, provided the ring remained in your vagina for three weeks, you insert the new ring on time and nothing else happened that could make the ring less effective (eg taking certain other medicines).
• Don't flush used rings down the toilet - dispose of them in a bin, preferably in one of the sealable sachets provided.
• You can use tampons while the ring is in your vagina, but check that the ring doesn't come out when you remove the tampon (see below). Don't use menstrual cups with NuvaRing.

When can I start using it?

• Check with your doctor because this depends on personal circumstances, such as if you're changing from another form of contraception, or if you're starting it after having a baby or following a miscarriage or abortion.
• Your doctor will also advise on how soon you'll be protected against pregnancy. For some women this will be as soon as they insert their first ring, but most women need to use condoms (or not have sex) until the ring has been in place for seven days. (Don't use female condoms, diaphragms or caps with NuvaRing.)

What if the ring accidentally comes out?

• It's important to regularly check that your ring is still in your vagina, particularly after removing a tampon, straining for a bowel movement and after having sex.
• If the ring accidentally comes out, rinse it in cool or lukewarm water and put it back in as soon as possible.
• If you put the ring back in within three hours you will still be protected from pregnancy.
• If the ring is out of your vagina for longer than three hours, or you don't know when it came out, then you may not be protected from pregnancy. If this happens in the first two weeks of ring use you should reinsert the ring as soon as possible and then either not have sex, or use condoms for the next seven days.

If the ring is out of your vagina for longer than three hours in the third week of use, you should throw that ring away and then either:

a) Insert a new ring straight away and miss your ring-free week. If you do this you don't need to use extra contraception. You may not have a withdrawal bleed but you may get some spotting.

b) Have your ring-free week and withdrawal bleed and insert a new ring no later than seven days after your ring came out. You will need to use condoms for the first seven days after inserting the new ring. (You should only choose this option if the ring was in place continuously for the seven days before it accidentally came out.)

What if I forget to remove the ring after three weeks?

• If you forget to remove the ring on time, take it out as soon as you remember.
• If the ring was in for less than four weeks, you can still have your one week ring free break, and then insert a new ring. You will still be protected from pregnancy.
• If the ring was left in for more than four weeks, then it will have become less effective and you should do a pregnancy test to make sure you are not pregnant before you insert a new ring. You will then need to use condoms or not have sex for the first seven days after the new ring is inserted.

What if I forget to insert a new ring after my one week break?

• If you forget to insert a new ring after your one week break, insert it as soon as you remember and either don't have sex, or use condoms for the next seven days. If you had unprotected sex during your ring-free break and forgot to insert the ring on time after the break, then it is possible that you could be pregnant. If you suspect you could be pregnant don't insert a new ring and consult your doctor.

What are the side effects of NuvaRing?

• Vaginal infections or discharge.
• Headache.
• Feeling sick.
• Abdominal pain.
• Breast pain or tenderness.
• Slight bleeding or spotting between periods in the first few months.
• Lighter periods or sometimes stopping of periods.
• Mood changes. However, there's no evidence that the ring causes depression.

Other possible side effects include:

• Cystitis or urinary tract infections.
• Inflammation of the cervix (cervicitis).
• Vaginal burning sensation, pain, discomfort, dryness or odour.
• Fluid retention. However, there's no evidence that the ring causes weight gain.
• Change in sex drive.
• Rise in blood pressure.
• Skin reactions.

Increased risk of getting a blood clot in an artery, which could cause a stroke or a heart attack.

Increased risk of getting a blood clot in a vein, such as a deep vein thrombosis (clot in the leg) or pulmonary embolism (clot in the lungs). But the risk is still small - each year between 6 and 12 women out of every 10,000 using NuvaRing will get this type of blood clot, compared with 2 women out of every 10,000 not taking the pill, and 29 out of every 10,000 women who are pregnant.

The risk of blood clots is also increased if you're travelling for long periods of time where you will be sat still (particularly flights over three hours). Ask your doctor or pharmacist for advice on using travel stockings, calf exercises or aspirin.

Stop using NuvaRing and see a doctor immediately if you get symptoms of a blood clot such as: stabbing pains and/or unusual swelling in one leg, pain on breathing or coughing, coughing up blood, sudden breathlessness, sudden severe chest pain, migraine or severe headache, sudden disturbance in vision, hearing or speech, sudden weakness or numbness on one side of the body, or if you collapse.

Can I use other medicines with NuvaRing?

Before you start using NuvaRing make sure you tell your doctor or pharmacist if you're already taking any other medicines, because some medicines can make it less effective at preventing pregnancy. For instance, if you regularly take any of the medicines below NuvaRing probably won't work for you, so you'll usually need to use a different form of contraception:

• certain antiepileptic medicines, such as carbamazepine, oxcarbazepine, perampanel, phenobarbital, primidone, phenytoin or topiramate
• some medicines for HIV, such as cobicistat, efavirenz, nevirapine or ritonavir
• the antifungal griseofulvin
• modafinil
• the antibiotics rifabutin or rifampicin for tuberculosis
• the herbal remedy St John's wort (Hypericum perforatum).

If you're prescribed a short course (up to two months) of any of these medicines this can also make NuvaRing less effective, and your doctor will usually recommend that you temporarily use a different form of contraception. If you want to keep using NuvaRing, talk to your doctor about what to do. You'll also need to use an extra method of contraception (eg condoms) for as long as you take the extra medicine and for at least four weeks after stopping it.

NuvaRing is not usually recommended if you're taking the antiepileptic medicine lamotrigine.

Antibiotics (other than rifampicin or rifabutin) won't make NuvaRing less effective and it's fine to take a course - you don't need to use extra contraception.

If you need to take emergency contraception while you're using NuvaRing, for example because you've inserted a ring late, be aware that the ellaOne brand (containing ulipristal) can make NuvaRing less effective. If you take this type of emergency contraception while using NuvaRing you should use extra contraception, such as condoms, for 14 days after taking it.

It's fine to use thrush treatments while you're using the ring.

What if I get pregnant while using NuvaRing?

• Experience with oral contraceptive pills has shown that in general if the pill fails or you miss pills and you do get pregnant while taking it, there is no evidence to suggest that the pills you have already taken will harm the baby. NuvaRing hasn't been around for as long as contraceptive pills, but there is no evidence to suggest that it would be harmful to a baby either. The NuvaRing should not be inserted if you are or think you could be pregnant. If you do fall pregnant, remove the ring and get advice from your doctor.

References:

https://www.medicines.org.uk/emc/product/6449/smpc

https://www.netdoctor.co.uk/medicines/sexual/a8709/nuvaring-ethinylestradiol-etonogestrel/

https://www.nuvaring.com

https://spunout.ie/health/article/vaginal-ring

https://www.mayoclinic.org/tests-procedures/nuvaring/about/pac-20394784

https://www.plannedparenthood.org/learn/birth-control/birth-control-vaginal-ring-nuvaring/what-are-benefits-nuvaring

https://www.plannedparenthood.org/learn/birth-control/birth-control-vaginal-ring-nuvaring