To assess a woman's eligibility for a combined contraceptive vaginal ring:

• In young women and women with special needs, assess their competence to decide, and support them in making their own decisions about contraception.
• Exclude pregnancy.
• Assess the woman's risk for sexually transmitted infection and, when appropriate, advise testing, promote safer sex, and/or refer for counselling.
• Advise the woman that the combined contraceptive vaginal ring does not protect against HIV or AIDS, or other sexually transmitted diseases.
• Check the woman's blood pressure.
• Check the criteria in Combined hormonal methods to ensure that the assessment is complete and that the woman is eligible for a vaginal ring. The restrictions applying to the combined contraceptive vaginal ring are identical to those applying to the combined oral contraceptive (COC) and combined patch.
• Women should not use a combined vaginal ring (UKMEC 4) in the following situations. Should any of the conditions appear for the first time during the use of the combined contraceptive vaginal ring, it should be removed immediately:
• Breastfeeding and less than 6 weeks postpartum.
• Age 35 or more years and smoking 15 cigarettes or more a day.
• Multiple risk factors for arterial cardiovascular disease (e.g. older age, smoking, diabetes, and hypertension) — UKMEC 3 if less severe.
• Hypertension not adequately controlled (systolic blood pressure equal to, or greater than 160 mmHg, OR diastolic blood pressure equal to, or greater than 95 mmHg).
• Vascular disease, including angina or other ischaemic heart disease, intermittent claudication, hypertensive retinopathy, transient ischaemic attacks, other cerebrovascular disease.
• History of, or current venous thromboembolism on anticoagulants.
• High risk of venous thromboembolism (e.g. major surgery with prolonged immobilization, known thrombogenic mutation, Raynaud's disease with lupus anticoagulant).
• Valvular or congenital heart disease if complicated by pulmonary hypertension, atrial fibrillation, or subacute bacterial endocarditis.
• Migraine with aura, at any age.
• Current breast cancer.
• Diabetes with nephropathy, neuropathy, retinopathy, or other vascular disease — UKMEC 3 if less severe.
• Cirrhosis of the liver, decompensated (e.g. ascites, jaundice, encephalopathy, or gastrointestinal haemorrhage).
• Liver tumours — benign (hepatocellular adenoma) or malignant (hepatoma).
• Specifically relating to the combined contraceptive vaginal ring, it should not be used if a woman has:
• Undiagnosed vaginal bleeding.
• Known or suspected malignant conditions of the genital organs, if sex steroid-influenced.
• Prolapse of the uterine cervix, cystocele and/or rectocele, or severe or chronic constipation (may cause difficulty with ring insertion, or increase the risk of losing it).
• Hypersensitivity to the active substances and excipients of the combined contraceptive vaginal ring.
• Women should use a combined contraceptive vaginal ring only after consultation with an expert (UKMEC 3) in the following situations:
• Breastfeeding and between 6 weeks and 6 months postpartum.
• Postpartum less than 21 days and not breastfeeding.
• Age 35 or more years, and stopped smoking for less than 1 year, or smoking less than 15 cigarettes a day.
• BMI greater than 35 kg/m².
• Multiple risk factors for arterial cardiovascular disease (e.g. older age, smoking, diabetes, and hypertension) — UKMEC 4 if more severe.
• Hypertension adequately controlled (systolic blood pressure less than 159 mmHg, AND diastolic blood pressure less than 94 mmHg).
• Family history of venous thromboembolism in a first-degree relative less than 45 years of age.
• Moderately increased risk of venous thromboembolism (e.g. immobility unrelated to surgery, wheelchair use, debilitating illness).
• Known dyslipidaemia with increased risk of cardiovascular disease.
• Migraine without aura, at any age, while using the combined vaginal ring.
• Past history (at least 5 years ago) of migraine with aura, at any age.
• Undiagnosed breast mass, carriers of known gene mutations associated with breast cancer (e.g. BRCA1), past history of breast cancer with no recurrence for 5 years or more.
• Diabetes with nephropathy, neuropathy, retinopathy, or other vascular disease — UKMEC 4 if more severe.
• Gall bladder disease, current or medically treated.
• History of cholestasis related to past COC use.
• Use of liver enzyme–inducing drugs (see Selected concurrent medications).

• Contraception for young women and women with learning disabilities:
• Contraception should be seen in terms of the needs of the woman rather than in terms of relieving the anxieties of carers or relatives.
• When a woman with a learning disability is unable to understand and take responsibility for decisions about contraception, carers and other involved parties should meet to address issues around the woman's contraceptive needs and to establish a care plan.
• See Considerations for girls under 16 regarding legal and ethical issues, but note that the combined contraceptive vaginal ring's safety and efficacy has only been established in women aged 18 to 40 years.
• The following examinations and laboratory tests are not required to assess eligibility for a combined contraceptive vaginal ring:
• Breast, pelvic, or genital examination.
• Cervical cytology screening.
• Routine laboratory tests including haemoglobin measurements.
• Thrombophilia screening.

• These recommendations for assessing a woman before starting a combined contraceptive vaginal ring are based on guidelines issued by the Faculty of Sexual and Reproductive Health Care (FSRH) UK medical eligibility criteria for contraceptive use (UKMEC) [FSRH, 2009b], New product review: combined vaginal ring (NuvaRing^®) [FSRH, 2009a], and the Summary of Product Characteristics for the NuvaRing^® combined vaginal ring [ABPI Medicines Compendium, 2009b].
• There is currently a lack of direct data on the safety of hormones delivered by the vaginal route [FSRH, 2009a]. Because the risks for users of the combined contraceptive vaginal ring are assumed to be similar to those for users of combined oral contraceptives (COCs), guidelines and evidence on the use of COCs largely applies to the ring (the exceptions are obvious and mainly relate to the differences in absorption routes).
• The examinations and investigations that are specifically not recommended to assess eligibility do not contribute substantially to the safety of women using combined hormonal contraceptives [British Society for Haematology, 2001; FFPRHC, 2007b].