Vaginal Ring

Question 1

Discuss the vaginal ring (NuvaRing).

Answer 1

Class: COC - etonogestrel with ethinyloestradiol

MOA: hormones released from the vaginal ring are absorbed into the systemic circulation:

• inhibit ovulation
• reduce receptivity of endometrium to implantation
• thicken cervical mucus to form a barrier to sperm

Indications: contraception

AEs:
Common
- vaginitis, vaginal discharge, irregular bleeding, device-related problems (eg foreign body sensation, expulsion of ring)

Rare
vaginal/cervical erosion or ulceration

Question 2

How would you counsel on the NuvaRing?

Answer 2

Counselling:
> directions
- insert ring into the vagina and leave for 3 weeks
- remove for a 1-week break on the same day of the week it was inserted, your period should start 2–3 days later
- then insert a new ring even if your period has not stopped
> when to start
- if no preceding hormonal contraceptive: for immediate contraception insert ring within the first 5 days of your period starting. If you insert the ring after this, use additional contraceptive methods until it has been in place for 7 days.
- if changing from a COC: insert ring the day after you take your last pill (on any day of your cycle). Additional contraception is not required.
- if changing from a progestogen-only pill: insert ring the day after the last pill is taken and use an additional contraceptive method until it has been in place for 7 days.
> managing problems
o If the ring comes out accidentally, rinse it with lukewarm water and re-insert as soon as possible. If the ring is lost, insert a new ring. If the ring has been out for:
- less than 3 hours, you should still be protected from pregnancy
- more than 3 hours, you may not be protected; use another contraceptive method until the ring has been in place for 7 days in a row (if this extends into the usual ring-free interval, miss the break and replace the ring with a new one). If the ring was left out during the first 7 days after the ring-free interval and you had unprotected sex in the 5 days before the ring was left out, seek emergency contraception.
o if you leave the ring in for too long, remove it as soon as possible. If the ring has been left in for:
- 4 weeks or less, insert a new ring after a 1-week ring-free period
- more than 4 weeks, consider the possibility of pregnancy; insert a new ring as soon as possible and use another contraceptive method (eg condoms) until the new ring has been in for 7 days in a row.
o if the ring-free interval is more than 1 week, consider the possibility of pregnancy. Insert a new ring and use another contraceptive method until the ring has been in for 7 days in a row.