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Contraception - Management
Expulsion of the combined contraceptive vaginal ring: what should be done?

  • Advise the woman to check the presence of the ring regularly (for example, pre-coitally) as there are reports that it may be expelled if it is not inserted properly, while removing a tampon, during sexual intercourse, or in severe or chronic constipation.
  • Prolonged expulsion may lead to contraceptive failure and/or breakthrough bleeding.
  • Deliberate removal of the ring is not recommended.
  • If the ring is removed or expelled and left outside the vagina for less than 3 hours, contraceptive efficacy is not reduced. The ring should be rinsed with cool to lukewarm water and reinserted as soon as possible, within 3 hours.
  • If the ring is expelled and left outside the vagina for more than 3 hours, contraceptive efficacy may be reduced. The following advice depends on which week of use this has occurred in.
    • If this has occurred during the first or second week of use, the woman should reinsert the ring as soon as she remembers. Additional barrier contraception should be used until the ring has been in the vagina continuously for 7 days. Assess the need for emergency contraception.
    • If this has occurred during the third week of use, the woman should discard the ring, and either:
      • Insert a new ring immediately, which will start a new cycle. Advise her that breakthrough spotting or bleeding may occur.
      • Have a withdrawal bleed, and insert a new ring no later than 7 days from when the previous ring was expelled.
Basis for recommendation
  • These recommendations are based on the Summary of Product Characteristics of the NuvaRing® combined vaginal ring [ABPI Medicines Compendium, 2009b].
    • The longer the time the ring has been out of the vagina, and the closer this is to the ring-free interval, the higher the risk of pregnancy.

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