Contraceptive Ring (NuvaRing)
What is the ring?
The ring is a reversible method of birth control that delivers a mix of estrogen and progestin just like a birth control pill. Instead of taking a daily pill, a woman inserts a flexible plastic ring into her vagina and into her vagina and leaves it in for three straight weeks. In the fourth week, it's taken out. When used correctly, the ring is 98 to 99 percent effective at preventing pregnancy. It doesn't protect against sexually transmitted diseases.
Who can use it
If you are already using hormonal contraception, your doctor may advise you to switch to the ring. However, it is important to know that a Swedish study examining the health records of more than 1 million women found that women using vaginal rings were 6.5 times more likely to develop blood clots than women not using hormonal contraceptives. (Nor were patches a better alternative: Women using transdermal contraceptive patches were 7.9 more likely to develop blood clots.) A number of lawsuits have been filed in the United States alleging that young women died from blood clots as a result of using NuvaRing and Yaz.
How do you use it?
Wash your hands with soap and water, then squeeze the ring between your thumb and forefinger and insert it into the vagina. The exact position is not important, as long as it feels comfortable. The manufacturer claims it will stay in place during all normal activities. After three weeks, remove it by hooking your finger on it and then gently pulling it out. (You should get your period soon after.) A week after removing a ring, you should put a new one in, even if you are still having your period.
What if my ring comes out?
If your ring has been out less than three hours, just rinse it with warm water and put it back in. During the first two weeks of the cycle, if it's been out for more than three hours you can still rinse and put it back in, but use a backup birth control method for a week. If it comes out during week three, you have two options: Toss it out and start a new ring (and new cycle) right away, or leave it out, have your period, and then put in a new ring a week from the time your ring originally came out. In either case, you'll reset your cycle and your ring-change day.
How effective is the ring?
According to the manufacturer, with perfect use (meaning that a woman always uses the ring consistently and correctly), it's estimated that for every 100 women who use the ring for a year, only one or two would become pregnant.
Certain medications and herbs can interact with hormonal contraceptives and make them less effective, including some drugs for seizures, headaches, sleeplessness, or anxiety, some oral antifungals (for yeast infections), and the antibiotic rifampin. Also, the herb St. John's wort (used to treat mild depression) may decrease the effectiveness of hormonal contraception. If you need to take any of these medicines, you may experience breakthrough bleeding (bleeding at times other than your period); if this happens, use a backup contraception method.
Vitamin C, acetaminophen (Tylenol), and atorvastatin (Lipitor) can increase the amount of hormones in your body. Miconazol nitrate (found in the vaginal yeast infection cream Monistat and other brands) can increase hormone levels by up to 40 percent. Several protease inhibitors for HIV can cause significant changes (increases and decreases) in the amount of hormones in the bloodstream. All these things can affect the contraceptive properties of the ring.
Does it have side effects?
As the ring delivers estrogen and progesterone, just like contraceptive pills, the side effects are generally similar to those caused by the pill. In clinical trials, the most common side effects reported by ring users (5 to 14 percent) were vaginal irritation or itching, headache, upper respiratory tract infection, vaginal discharge, sinusitis, weight gain, and nausea. Also, in some trials as many as 2.5 percent of women decided to stop using the ring. The most common reasons for this were physical problems with the ring (not liking the way it felt, having the ring fall out), vaginal symptoms (discharge, irritation), headache, mood swings, and weight gain.
It's common for your periods to become lighter or stop altogether while using the ring, and you may also notice spotting or "breakthrough bleeding." Other side effects of combination hormone birth control may include breast swelling or tenderness, vision changes, abdominal cramps, rash, yeast infections, depression, and jaundice (yellowing of eyes or skin due to liver problems).
If you smoke (especially if you're over 35), have had a blood clot or stroke before, or have high blood pressure that's not under good control (over 140/90), you should avoid combination hormone birth control methods such as the pill and the ring, because the estrogen in them increases your risk of blood clots that can cause stroke and heart attack. Also, if you have a family history of clotting disorders, such as deep vein thrombosis or Factor V Leiden deficiency, some doctors advise genetic testing to rule out the possibility that you are affected before starting any estrogen therapy.
The hormones in the pill and ring can increase blood pressure, causing hypertension in some women. They can also raise LDL ("bad" cholesterol) and triglyceride levels, and women with high lipid (blood fat) counts or a family history of premature heart disease should have their levels checked. The hormones can also worsen glucose tolerance, so women with risk factors for diabetes (pre-diabetes, diabetes in pregnancy) should be tested and monitored. Some women with diabetes have dramatic changes in blood glucose levels when they start hormonal contraceptives.
On the plus side, taking combination pills decreases your risk for endometrial and ovarian cancer. Now for the bad news: Some experts say that taking combination birth control of any type may increase risk for breast cancer if you have a family history of it, although this conclusion is controversial. Some studies have found a slightly higher breast cancer risk among pill users, especially among younger women, but the risk tends to normalize 10 years after going off the pill. There is also evidence that long-term use of combination oral birth control increases the risk of cervical cancer. And according to the International Agency for Research on Cancer, if you are positive for human papilloma virus, or HPV, being on the pill (or ring) for five years or more may quadruple your risk of developing cervical cancer.
If you have breast cancer (past, present, or suspected) or unexplained vaginal bleeding, you may be advised to avoid all forms of hormonal birth control. The ring also may not be right for you if you have heart disease, liver or gallbladder disease, lupus, diabetes with vascular disease, severe migraines, or other conditions that may conflict with hormone use. Estrogen affects milk production, so if you are breastfeeding you should not use NuvaRing, according to the manufacturer.
How can I get the ring?
Since it contains the same hormones as the pill, the ring is available by prescription only. If you're interested, talk to your doctor or health care provider to find out if it's a good choice for you. The cost can range from $15 to $50 per month. Many insurance plans now cover prescription contraceptives, so check with your insurance for details. If you don't have insurance you may be able to get it at a subsidized price at community or university clinics.
If you want an even more "hands-off" birth control while keeping your pregnancy options open, you might consider the quarterly progestin shot (Depo-Provera), three-year progestin implant (Implanon), or the five-year intrauterine system (the Mirena IUS, an IUD that releases progestin). All these options contain hormones. For a low-maintenance option without hormones, consider ParaGard, the standard intrauterine device or IUD, which can be left in up to 10 years.
NuvaRing manufacturer information
Lidegaard, Ojvind, et al. "Venous Thombosis in users of non-oral hormonal contraception: follow-up study," Denmark 2001-10, BMJ 2012; 344, May 10, 2012.
FDA: Questions and Answers for Estrogen and Estrogen with Progestin Therapies for Postmenopausal Women.
Moreno, et. al. Effect of oral contraceptives on risk of cervical cancer in women with human papillomavirus infection: The IARC multicentric case-control study. Lancet, 2002 Mar 30; 359(9312) 1085-92
NCI Factsheet: Contraception and Cancer . 2006
Cardiovascular Research Foundation: Birth Control Pills
Drugstore.com: NuvaRing 12/7/10
Emily Herndon, MD and Miriam Zieman, MD, New Contraceptive Options. American Family Physician, Feb 15, 2004.
American College of Obstetricians and Gynecologists. Contraception While Breastfeeding.
Mayo Clinic. Injection (Depo-Provera).
Mayo Clinic. Implanon: FDA Approves Implantable Contraceptive.