NuvaRing (combined contraceptive vaginal ring)

Vaginal ring containing 11.7 mg etonogestrel and 2.7 mg ethinylestradiol per ring (NuvaRing, Syreniring)

NuvaRing is a flexible, transparent plastic ring 5.4cm in diameter and 0.4cm thick

• after insertion into the vagina, it releases 120 µg etonogestrel (the active metabolite of desogestrel) and 15 µg ethinyloestradiol per 24 hours over a period of three weeks
• the ring is then removed, provoking withdrawal bleeding, and a new one is inserted one week later

The Summary of Product Characteristics (SPC) explains when to start use following previous or no contraception and details the actions to take if the ring is not inserted at the correct time, is expelled or left out.

NuvaRing acts systemically and its positioning is not critical (1)

• vaginal absorption of etonogestrel and desogestrel achieves blood levels that are comparable with those associated with a combined oral contraceptive (COC) and NuvaRing inhibits ovulation to a comparable extent

Precautions and contraindications to its use are similar to those for COCs (1,2)

Cautions including any relevant action to be taken (2):

• If the individual is less than 16 years of age an assessment based on Fraser guidelines must be made and documented
• If the individual is less than 13 years of age the healthcare professional should speak to local safeguarding lead and follow the local safeguarding policy.
• Discuss with appropriate doctor/independent non-medical prescriber any medical condition or medication of which the healthcare professional is unsure or uncertain.
• Individuals taking lamotrigine should be advised that CHC may interact with lamotrigine; this could result in reduced seizure control or lamotrigine toxicity.
• Offer Long Acting Reversible Contraception (LARC) to all individuals in particular those with medical conditions for whom pregnancy presents an unacceptable risk and those on a pregnancy prevention plan
• If an individual is known to be taking a medication which is known to be harmful to pregnancy a highly effective form of contraception is recommended. Highly effective methods include the LARC methods: IUD, IUS and implant. If a LARC method is unacceptable/unsuitable and a CHC is chosen then an additional barrier method of contraception is advised. See FSRH advice

Dose and frequency of administration (2)

• The vaginal ring releases an average amount of 0.12 mg etonogestrel and 0.015 mg ethinylestradiol respectively per 24 hours, over a period of three weeks.
• FSRH guidance states that CHC can either be used following a standard or tailored regime.
• Individuals should be given information about both standard and tailored CHC regimens to broaden contraceptive choice.

Regimes

• The vaginal ring can either be used as a standard regime or in a tailored regime depending on the choice of the individual.
• The regimes which can be advised are detailed below:

• For the regimes detailed above a single ring is to be inserted every 21 days starting on day 1-5 of the menstrual cycle with no need for additional precautions.
• The ring can be inserted at any time after day 5 if it is reasonably certain that the individual is not pregnant. Additional contraception is then required for seven days after starting.
• Thereafter the dosage regime detailed above should be followed. Individuals should have access to clear information (either written or digital) to support tailored CHC use
• When starting or restarting the CHC as quick start after levonorgestrel emergency contraception, additional contraception is required for 7 days and a pregnancy test should be performed 21 days after the last unprotected sexual intercourse.
• In line with FSRH guidance individuals using hormonal contraception should delay restarting their regular hormonal contraception for 5 days following ulipristal acetate use. Avoidance of pregnancy risk (i.e. use of condoms or abstain from intercourse) should be advised until fully effective
• For guidance on changing from one contraceptive method to another, and when to start after an abortion and postpartum, refer to the FSRH guidance

Insertion or retention may be impossible for women with a prolapsed cervix, a cystocele or rectocele, or severe or chronic constipation

The following possible adverse effects are commonly reported with CHC (but may not reflect all reported adverse effects) (2):

• Nausea
• Breast tenderness
• Headache
• Temporary disturbances of bleeding patterns
• Change in mood
• Fluid retention

Serious adverse effects - these are less common but the risks should be discussed with the individual (2):

• Venous thromboembolic events (VTE)
• Arterial thromboembolic events (ATE) including transient ischaemic attack, ischaemic stroke, heart attack and ischaemic heart disease
• Hypertension

With respect to NuvaRing (1):

• systemic adverse effects associated with NuvaRing are similar to those of a COC
• NuvaRing is also associated with vaginal infection (3.9-4.6 per cent attributed to NuvaRing vs 1.0-2.1 per cent with a COC) and discharge (3.5-4.8 vs 0.2-1.0 per cent)
• commonest adverse effect reported in comparative clinical trials was headache, affecting approximately 6-8 per cent of women in each treatment arm
  • method-related events were the commonest reason for discontinuation due to adverse events and were attributed to the medication in 5 per cent of women with NuvaRing and 0.4 per cent with the COC

Efficacy:

• trial evidence comparing the COC and NuvaRing revealed that, after 13 cycles there was no significant difference in contraceptive efficacy
• overall compliance was 87 per cent in both groups

Reference:

• 1) Chaplin S, Peers T. NuvaRing: new combined hormonal contraceptive device. Prescriber 2009; 20 (12): 17-20.
• 2) Patient Group Direction (PGD) (NHS Specialist Pharmacy Service). Supply of combined hormonal contraceptive vaginal ring. (Accessed 17th March 2021).