Classes
DEA Class; Rx
Common Brand Names; NuvaRing, EluRyng
- Estrogens/Progestins
Description
Vaginal combined hormonal contraceptive ring containing etonogestrel, a progestin of low androgenic and negligible estrogenic activity, and ethinyl estradiol
Used for routine contraception in adolescent and adult premenopausal females; vaginal ring is left in place for 3 weeks, followed by a 1 week hiatus; women at increased risk for vaginal expulsion or irritation are not the best candidates for use
All combined hormonal contraceptives contain a boxed warning regarding the increased risk for thromboembolism in women who smoke
Indications
Indicated for use by females of reproductive age
Indicated for routine contraception under the following conditions.
- Switching from a combination oral contraceptive.
- Switching from a progestin-only method.Following complete first trimester abortion.Following delivery or second trimester abortion.
Contraindications
Documented hypersensitivity
Arterial thromboembolic disease (stroke, MI), thrombophlebitis, DVT/PE, thrombogenic valvular disease
Estrogen-dependent neoplasia (current or history of)
Cerebrovascular disease, coronary artery disease
Headaches with focal neurological symptoms
Liver disease, liver tumors
Undiagnosed abnormal vaginal bleeding
Uncontrolled hypertension
Women >35 years who smoke
Major surgery with prolonged immobilization
Diabetes mellitus with vascular involvement, jaundice with prior oral contraceptive use
Breast cancer or other estrogen-or progestin-sensitive cancer,now or in the past
Use of hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, due to potential for ALT elevations
Adverse Effects
- Vaginitis (13.8%)
- Headache (including migraine) (11.2%)
- Mood changes (6.4%)
- Device-related events (eg, expulsion/discomfort/foreign body sensation) (6.3%)
- Nausea/vomiting (5.9%)
- Vaginal discharge (5.7%)
- Increased weight (4.9%)
- Vaginal discomfort (4%)
- Breast pain/discomfort/tenderness (3.8%)
- Dysmenorrhea (3.5%)
- Abdominal pain (3.2%)
- Acne (2.4%)
- Decreased libido (2%)
- Immune system disorders: Hypersensitivity (anaphylaxis and angioedema)
- Nervous system disorders: Stroke/cerebrovascular accident
- Vascular disorders: Arterial events (including arterial thromboembolism and myocardial infarction), aggravation of varicose veins
- Skin and subcutaneous tissue disorders: urticaria, chloasma
- Reproductive system and breast disorders: penile disorders, including local reactions on penis (in male partners of women using NuvaRing), galactorrhea
- Injury, poisoning and procedural complications: Vaginal injury (including associated pain, discomfort, and bleeding) associated with ring breakage
Warnings
Avoid using diaphragm concomitantly; may interfere with ring placement
Family history of breast cancer and or DVT/PE
Use caution in current/history of depression, endometriosis, DM, HTN, bone mineral density changes, renal/hepatic impairment, bone metabolic disease, SLE; conditions exacerbated by fluid retention (eg, migraine, asthma, epilepsy)
Known risk factors for VTE include smoking, obesity, and family history of VTE, in addition to other factors that contraindicate use of CHCs; stop use if arterial thrombotic or venous thromboembolic event (VTE) occurs or if there is unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions; evaluate for retinal vein thrombosis immediately
The risk of VTE is highest during first year of CHC use and after restarting a CHC following a break of at least four weeks; risk of VTE due to CHCs gradually disappears after use is discontinued
Discontinue if the following develop jaundice, visual problems (may cause contact lens intolerance), migraine with unusual severity, significant blood pressure increase, severe depression, increased risk of thromboembolic complications after surgery
Discontinue 4 week before major surgery or prolonged immobilization
Discontinue if an arterial thrombotic or venous thromboembolic event occurs
Estrogens may cause retinal vascular thrombosis; discontinue therapy if visual disturbances occur including migraine, loss of vision, diplopia, or proptosis
Patients on warfarin, oral anticoagulants (increase in anticoagulant dose may be warranted)
Increased risk of cervical cancer with OCP use, however HPV remains as main risk factor for this cancer, evidence suggests long-term use of OCPs, 5 or more years, may be associated with increased risk
Increased risk of liver cancer with OCP use; risk increases with longer duration of OCP use
Combination of hormonal contraceptives may affect lipoprotein levels and serum triglycerides
Use of CHCs may worsen existing gallbladder disease; past history of CHC-related cholestasis predicts an increased risk with subsequent CHC use; women with a history of pregnancy-related cholestasis may be at increased risk for CHC-related cholestasis
Pregnancy and Lactation
Extensive epidemiological studies have revealed no increased risk of birth defects in women who have used oral contraceptives prior to pregnancy; studies also do not suggest a teratogenic effect, particularly insofar as cardiac anomalies and limb reduction defects are concerned, when taken inadvertently during early pregnancy
Small amounts of oral contraceptive steroids identified in the milk of nursing mothers, and a few adverse effects on child reported, including jaundice and breast enlargement; in addition, oral contraceptives given in postpartum period may interfere with lactation by decreasing quantity and quality of breast milk
Maximum Dosage
1 ring/month PV.
Not indicated.
1 ring/month PV.
Not indicated in prepubescent females
How supplied
Etonogestrel/ethinyl estradiol
vaginal ring
- 0.12mg/0.015mg released per day