Choosing a Birth Control Method – Vaginal Ring

(Updated June 2014)

Description

The vaginal ring (NuvaRing^®) is a flexible, transparent ring placed in the vagina. When inserted, the ring delivers 120 mcg of a type of progestin called etonorgestrel and 15 mcg of ethinyl estradiol per day to the systemic circulation over a 3-week period to inhibit ovulation. The vaginal ring contains 4 weeks of hormones. It comes in one size that fits most women; no fitting is required. The vaginal ring has one of the highest satisfaction rates among users.³³

Use

One ring is inserted into the vagina per cycle and remains in place continuously for 3 weeks, followed by a ring-free week. The old ring should be discarded in the foil packet provided and a new ring inserted after the ring-free week. Use of the ring can be started at any time during the menstrual cycle. For continuous-use contraception, the patient can change the ring every 4 weeks without taking a 1-week break.

Effectiveness

• This method is very effective. The contraceptive efficacy of the vaginal ring is comparable to that of COCs and the patch.
• The failure rate is 0.3 percent with perfect use and 9 percent with typical use.¹⁹

Risks

As described previously for all combined hormonal contraception.

Side Effects

As described previously for all combined hormonal contraception. Events directly related to the ring, such as expulsion during intercourse or other times, and increased vaginal secretions are uncommon; less than 3 percent of women discontinue use due to such events. It is rare for the user or her partner to feel the ring during sexual intercourse. Irregular bleeding also is uncommon.³⁴

Contraindications

As described previously for all combined hormonal contraception, plus:

• Vaginal obstruction
• Lack of comfort with touching genitalia

Advantages

As described previously for all combined hormonal contraception, plus:

• Convenient, once-a-month use
• Excellent cycle control from the first month of use for most women³⁵
• Does not require special fitting
• Extra protection built in; if a woman forgets to remove the vaginal ring after 21 days, serum hormone levels will remain in the contraceptive range for up to 1 additional week
• Potential for improved adherence

Disadvantages

As described previously for all combined hormonal contraception, plus:

• Patient must remember to remove ring after 3 weeks, then insert another after a 1-week break
• May increase normal vaginal secretions

Counseling Messages

• The ring is easy to insert and can be placed anywhere in the vagina; however, the deeper the placement, the less likely it will be felt. (Providers can consider offering a trial ring in the office to help reassure women who are skeptical about comfort and ease of use.)
• After 3 weeks, the ring should be removed; 1 week later a new ring should be inserted.
• The ring can be inadvertently expelled from the vagina while during removal of a tampon or bowel and bladder emptying, especially with straining or constipation. Often women are not aware that the device has been expelled.
• Most women wear the ring during intercourse. It is rarely uncomfortable, it rarely interferes with intercourse, and few partners object.³⁶
• If there is a problem with intercourse, the ring can be removed for up to 3 hours without loss of efficacy.
• Non-hormonal back-up contraception is needed for first 7 days if the ring is started on any day other than day 1 of the menstrual cycle.
• If the ring falls out, it should be rinsed with warm water and reinserted within 3 hours. Back-up contraception is required for 7 days if the ring remains out for more than 3 hours.
• This method does not protect against STIs.