The Ring ? NuvaRing ? is a reversible prescription method of birth control. It is a small, flexible ring that is inserted into the vagina once a month. It is left in place for three weeks and taken out for the remaining week. The ring releases synthetic estrogen and progestin to protect against pregnancy for one month.

The combination of hormones works in two ways. Usually, it keeps the ovaries from releasing an egg (ovulation). Less often it thickens the cervical mucus, which prevents sperm from joining with an egg. The hormones also thin the lining of the uterus. In theory, this could prevent pregnancy by interfering with implantation of a fertilized egg. But there is no scientific evidence that this occurs.

Pregnancy can happen if an error is made in using the ring ? especially if

• the unopened package is exposed to very high temperatures or direct sunlight
• it slips out of the vagina and is not replaced within three hours
• it does not stay in the vagina for three weeks in a row
• it is left in the vagina for more than three weeks

If any of these things happen, follow the directions in your package insert, and call your clinician.

Effectiveness

Certain medicines, including the antibiotic rifampin, certain drugs used to treat mental illness or to control seizures, certain anti-fungals that are taken orally for yeast infections, or certain HIV protease inhibitors may make the ring less effective. Ask your clinician for advice. Until then, use an additional method of birth control.

The regular use of oil-based vaginal anti-fungals (medicines for yeast infections) while the ring is in place may increase the level of hormones released into the blood. This will not reduce the effectiveness of the ring.

It is very important to remember that the ring does not protect against sexually transmitted infections. Always use a latex or female condom with the ring to reduce the risk of infection.

*Typical use refers to failure rates for women whose use is not consistent or always correct.
**Perfect use refers to failure rates for those whose use is consistent and always correct.

Getting the Ring

You will insert one new ring into the vagina and keep it in place for three weeks in a row. Then remove it for one week.

• Check the expiration date of each ring package before insertion.
• Count the first day of your menstrual period as "day one" and plan to insert the ring between day one and day five of your cycle.
• Wash hands with soap and water.
• Use your fingers to press the sides of the ring together.
• Insert the ring gently into the vagina.
• The exact position of the ring doesn't matter.
• Do not remove the ring during vaginal intercourse.
• Remove it in three weeks on the same day of the week that it was inserted.
• Hook your finger under the forward rim and gently pull out of the vagina.
• Wrap it up in the original foil wrapper, and throw it out in the trash ? do not flush.
• After one week without the ring, insert a new one ? on the same day of the week that the previous one was inserted in your last cycle.

During the one-week break, you will usually have your menstrual period. You may still be bleeding when it is time to insert a new ring. This is normal, too. But the ring must be inserted on the same day of the week as it was inserted in the last cycle, or pregnancy may occur.

Be sure to have checkups at least once a year. See your clinician right away if any problem develops. Remember to tell any other clinician you may see that you are using the ring.

Advantages

Using the ring is simple, safe, and convenient.

Many women who use the ring have more regular, lighter, and shorter periods. And a woman's ability to become pregnant returns quickly when use of the ring is stopped.

The ring does not interfere with having sex, and may improve a woman's sex life. Some women say they feel free to be more spontaneous because they do not have to worry about becoming pregnant.

Results of long-term studies won't be available for some time, but researchers assume that the non-contraceptive advantages associated with the Ring are similar to those known to be associated with the pill. These health benefits may include some protection against

• irregular menstrual cycles
• infection of the fallopian tubes (pelvic inflammatory disease), which often leads to infertility
• ectopic pregnancy (in the fallopian tubes)
• noncancerous breast growths
• ovarian cysts
• cancer of the ovaries
• cancer of the lining of the uterus
• troublesome menstrual cramps
• iron deficiency anemia that results from heavy menses
• acne
• premenstrual symptoms, as well as related headaches and depression
• excess body hair
• osteoporosis ? loss of bone mass
• vaginal dryness and painful intercourse associated with menopause

Common Side Effects and Disadvantages

Side effects that usually clear up after two or three months of use include

• bleeding between periods
• weight gain or loss
• breast tenderness
• nausea ? rarely, vomiting
• changes in mood

Other possible side effects include

• increased vaginal discharge
• vaginal irritation or infection

Serious problems do not occur very often. Women who use combined hormone contraceptives have a slightly greater chance of certain major disorders than nonusers. The most serious is the rare possibility of blood clots in the legs, lungs, heart, or brain, and/or liver tumors.

The risks are increased by being 35 or older, smoking, and having conditions associated with heart disease ? such as diabetes, high blood pressure, or high levels of cholesterol ? and certain inherited conditions that increase the risk of blood clotting.

Women using combined hormone contraception who undergo major surgery seem to have a greater chance of having blood clots. Blood clots in the legs occur with increased frequency for women and men who

• have one or both legs immobilized
• are confined to their beds

It is important to tell your surgeon that you are using the ring when planning a major operation. Follow your surgeon's advice about when to resume combined hormone contraception after surgery.

Rarely, women who use combined hormones develop high blood pressure. Very rarely, liver tumors, gallstones, and jaundice (yellowing of the skin or eyes) occur in women who use combined hormones. More detailed information about the use and risks of the ring is provided in an insert included with each one.

Combined hormone contraception and breast cancer ? The most recent literature suggests that combined hormone contraception has little, if any, effect on the risk of developing breast cancer.

You should not use the ring if you

• smoke cigarettes and are 35 or older
• have had a heart attack or certain kinds of stroke
• have uncontrolled high blood pressure
• have controlled blood pressure and smoke more than 15 cigarettes a day
• have a history of certain inherited blood clotting disorders
• have a history of blood clots or vein inflammation
• have a history of serious heart valve problems
• have had an abnormal growth or cancer of the breast or uterus
• have a severe liver disease or have had growths on the liver
• have certain vascular conditions associated with diabetes mellitus
• are or think you might be pregnant
• need prolonged bed rest after major surgery
• have migraine headache with aura
• have weak pelvic floor muscles
• have chronic constipation

Women cannot use a diaphragm, cap, or shield for a back-up method of birth control while they are using the ring.

Some women can use the ring under close medical supervision if they have

• unexplained bleeding from the vagina
• a high risk for heart disease
• high cholesterol or slightly increased blood pressure
• certain kinds of migraine headaches
• a seizure disorder that requires taking anticonvulsant medication
• had or have diabetes ? not associated with vascular conditions
• gallbladder disease
• a certain cancer of the nervous system called meningioma
• experienced jaundice (yellowing of the skin) with prior birth control use
• have a parent or sibling who has had a heart attack or stroke before age 55

For most women with these conditions, the risks of pregnancy are more dangerous than the risks of using the ring.

Women with a history of depression may not be able to continue to use the ring if their depression worsens.

Early warning signs
Serious problems are rare but they usually have warning signs. Watch for them. If one occurs, report it to your clinician as soon as possible. These warning signs include

• sudden or constant pain or redness and swelling in the leg
• pain in the abdomen, chest, or arm
• sudden shortness of breath or spitting up blood
• severe headaches
• eye problems such as blurred or double vision
• worsening depression
• yellowing of the skin or eyes (jaundice)
• unusual heavy bleeding from the vagina
• a new lump in your breast
• no period after having a period every month

Pregnancy and the Ring

However, a missed period does not always mean you are pregnant, especially if you have used the ring correctly. But see your clinician if you miss a second period.

It is unlikely that using the ring during early pregnancy will increase the risk of defects in the fetus.

If you want to become pregnant, stop using the ring. If you want to plan the timing of your pregnancy, use another form of birth control until your period becomes regular. It usually takes about one to three months for your period to return to the cycle you had before using the ring.

After childbirth, your clinician can help you decide when to use the ring again.

Starting the Ring After Pregnancy

The ring may reduce the amount and quality of milk in the first six weeks of breastfeeding. Also, the milk will contain traces of the ring's hormones. If you are breastfeeding, wait at least six weeks after childbirth to insert the ring. Use a backup method for seven days if you have not yet gotten your period.

You can start using the ring immediately after having an abortion. Use a backup method of birth control for seven days if you start the ring

• more than five days after a vacuum aspiration abortion
• more than seven days after taking mifepristone

The Cost

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