Dear Reader,

NuvaRing, a new contraceptive, is a clear, flexible, and thin polymer ring (2½ inches in diameter and an 1/8 of an inch thick) that provides a continuous low dose of etonogestrel and ethinyl estradiol (a progestin and estrogen) to prevent pregnancy. A woman or her partner inserts the contraceptive ring inside her vagina and then it remains in place for three consecutive weeks. At the beginning of the fourth week, the woman removes the ring by using her index finger as a hook to retrieve and pull until it pops out. During the week that the ring is not inside of her, she will get her period. Then she places another one inside, after a week of being ring free. During the entire month, from insertion through the week when the ring is not in place, a woman is continually protected from pregnancy. However, similar to the birth control pill, it takes seven days to take effect, so that in order to be protected from pregnancy during that first week (and that first week alone), a condom needs to be used as backup pregnancy prevention. Using a condom with NuvaRing can also protect against sexually transmitted infections (STIs).

Approved by the U.S. Food and Drug Administration (FDA), NuvaRing, available by prescription, is 98 to 99 percent effective when used correctly. The ring works the same way as the birth control pill and the Ortho Evra contraceptive patch. All are combination hormonal contraceptives that prevent pregnancy by suppressing ovulation (meaning that the ovaries do not release the monthly egg) and causing the cervical mucus to thicken, making it difficult for sperm to enter the uterus. Women interested in NuvaRing can contact their health care provider. Because it is still fairly new, health care providers may not yet offer it or even be aware of this new contraceptive option.

When using this contraceptive ring, women are advised not to smoke, breastfeed, or use a diaphragm. NuvaRing, similar to birth control pills, is not recommended for women with any of the following:

• pregnancy or suspect a pregnancy
• current or previous blood clots in the legs, lungs, or eyes
• chest pain
• had a heart attack or stroke
• severe high blood pressure
• diabetes with kidney, eye, nerve, or blood vessel complications
• headaches with neurological symptoms
• have or suspect cancer of the breast, lining of the uterus, cervix, or vagina
• unexplained vaginal bleeding
• yellowing or whitening of the eyes or skin during pregnancy or past use of oral contraceptives
• liver tumors or active liver disease
• diseases of the heart valves with complications
• a need for a long period of bed rest following major surgery
• an allergy to any of the components of NuvaRing

In addition, women who have any of the following conditions should only use the contraceptive ring under close supervision of a health care provider:

• a family history of breast cancer
• breast nodules, fibrocystic disease, an abnormal breast X-ray, or abnormal mammogram
• diabetes
• high blood pressure
• high cholesterol or triglycerides
• headaches or epilepsy
• depression
• gallbladder or kidney disease
• major surgery (the contraceptive ring may need to be removed temporarily to reduce the possibility of developing blood clots)
• any condition that causes vaginal irritation
• a prolapsed uterus, bladder, or rectum
• severe constipation

Beginning to use NuvaRing depends on whether or not a woman has been using a hormonal contraceptive during the previous month, as well as on the type of birth control method she had been using, if any.

For women who have not used a hormonal contraceptive in that time period:

Insert NuvaRing into the vagina during menstruation. The first day of bleeding is considered day 1. NuvaRing needs to be inserted between day 1 and day 5.

For women who are switching from a combination oral contraceptive (birth control pills that contain both progestin and estrogen):

Insert NuvaRing within the first seven days after taking the last combined pill of the pack cycle. If the pill has been taken for more than one pill cycle, it is likely that NuvaRing will immediately protect against pregnancy.

• If it's a mini-pill, insert NuvaRing the very next day. This can be done on any day of the month.
• If it's an implant or progestin-containing IUD (intrauterine device), insert NuvaRing on the same day that the implant or IUD is removed.
• If it's an injectable contraceptive, insert NuvaRing on the day that the next injection is due.

In all of these cases, it is important to use a back-up method of contraception during the first seven days, as the ring is not likely to prevent pregnancy at this time. Use a condom, instead of a diaphragm or cervical cap, since NuvaRing can interfere with the correct placement and position of these methods of contraception.

To insert the contraceptive ring:

• Wash and dry your hands and remove the ring from the foil pouch (keep the pouch for disposal after use).
• Find a comfortable position — lying down, squatting, or standing with one foot resting on a higher surface, such as a stool, bed, chair, or bathtub.
• Hold NuvaRing between your thumb and index finger, pinching the ring so that it becomes long and narrow.
• Using your index finger, gently insert the narrowed ring into your vagina. When inside, if you can feel the ring, use your finger simply to position it farther into your vagina until it is comfortable. NuvaRing will not go in too deep or get lost inside your vagina.
• After the ring is in place, it stays in the vaginal canal for three weeks, when it is finally removed.

To remove the contraceptive ring:

• After the completion of the third week, remove NuvaRing on the same day and at around the same time that it was inserted.
• Insert your finger into your vagina and hook your finger under the rim or grasp it between the index and middle finger, pulling it out.
• Place the used ring in the original foil pouch and discard in the trash.

These directions sound complicated, but so would the process of toothbrushing if we were to identify each step. The process gets easier with practice, and again, similar to toothbrushing, we do it, after a while, without thinking.

A woman's next menstrual period will usually start 2 to 3 days after the ring is removed. To continue to prevent a pregnancy, a woman can insert a new ring one week from the time the last one was removed, even if menstruation continues, on the same day of the week and at or around the same time as it was inserted during the last cycle.

If the ring has not been inserted properly, the ring can slip out of the vagina. Sometimes this happens when removing a tampon or exerting force, such as during a bowel movement. If it does slip, and it has been less than three hours, a woman is still protected from pregnancy. Before reinserting the ring, rinse it with cool to lukewarm water and reinsert it as soon as possible within the three-hour time span. If NuvaRing needs to be replaced, insert a new one within the three-hour time span and continue on the same schedule as if it were the same ring.

If NuvaRing has been out of a woman's vagina for more than three hours, she may reinsert the ring as soon as possible, following the same procedure listed above. However, she may not be protected against pregnancy. Therefore, it is important to use a condom during the next seven days.

Common side effects of NuvaRing (similar to those of birth control pills) may include:

• vaginal discharge, infections, and irritation
• headaches
• weight gain
• nausea

Possible side effects of NuvaRing (similar to those of birth control pills) may include:

• blood clots
• increased risk of:
  • heart attacks and strokes
  • high blood pressure and heart disease
  • cancer of the breast
  • gallbladder disease
  • liver tumors

Check with your health care provider if you are taking any other prescription medications, such as antibiotics, so that a check for interactions can be done. In the event of an interaction, it's important to use a condom to prevent a possible pregnancy.

More detailed information about NuvaRing is available on the Center for Drug Evaluation and Research web site of the FDA and the NuvaRing manufacturer's web site.

Alice

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