• There is one combined contraceptive vaginal ring currently available in the UK. This is marketed as NuvaRing^®, which is a flexible, latex-free, transparent, and colourless to almost colourless vaginal ring.
• The ring releases etonogestrel and ethinylestradiol at an average amount of 120 micrograms and 15 micrograms respectively per 24 hours, over a period of 3 weeks.

In depth

• 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.
• Check the woman's blood pressure.
• Check the UK Medical Eligibility Criteria to ensure that there are no contraindications.
• Assess the risk for sexually transmitted infection and, when appropriate, advise testing, promote safer sex, and/or refer for counselling. Advise the woman that the ring does not protect against HIV or AIDS, or other sexually transmitted diseases.
• 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 risk of losing it).
• Hypersensitivity to the active substances and excipients of the combined contraceptive vaginal ring.

In depth

• New users with no previous hormonal contraception and no recent childbirth or abortion:
• Insert the ring on day 1 of the menstrual cycle for immediate contraceptive cover.
• If inserted on days 2–5 of the menstrual cycle, use additional barrier contraceptive cover for 7 days.
• Starting immediately after oral emergency contraception:
• Levonorgestrel emergency contraception used — advise additional contraception (condoms or avoidance of sex) for the first 7 days of use.
• Ulipristal acetate emergency contraception used — advise additional contraception (condoms or avoidance of sex) for the first 14 days of use.
• Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of unprotected sex.
• If changing from a combined hormonal contraceptive, insert the ring at the latest on the day following the usual tablet-free, patch-free or placebo tablet interval of her previous combined hormonal contraceptive. If she has been using the method consistently and correctly and she can exclude pregnancy, she may also switch on any day of the cycle.
• If changing from a progestogen-only method, switch on any day of the progestogen-only pill, implant or levonorgestrel-releasing intrauterine system on the day of its removal, and from the injection when the next injection is due. Use additional barrier contraceptive cover for 7 days.
• Note: as there is a small theoretical risk of implantation of a previously fertilized egg once the levonorgestrel-releasing intrauterine system (or other intrauterine device) is removed, women should be additionally advised to abstain from intercourse or use another method of contraception for at least 7 days before planned removal.
• After miscarriage up to 24 weeks:
• If the ring is started within 7 days of the miscarriage no additional contraceptive method is needed. If started after 7 days, additional barrier contraception is advised for 7 days.
• After miscarriage after 24 weeks:
• Women should insert the ring 21 days after the miscarriage.
• After first-trimester abortion:
• Insert the ring immediately within 24 hours after abortion for immediate contraceptive cover.
• If inserted later, she should use additional barrier contraceptive cover for 7 days after the ring is inserted, and should use an alternative contraceptive method in the meantime.
• Postpartum women who are not breastfeeding, and after second-trimester abortion:
• Insert the ring 21 days after delivery or abortion for immediate contraceptive cover.
• If inserted later, use additional barrier contraceptive cover for 7 days.

In depth

• Insert one ring high into the vagina for 3 weeks of continuous use per cycle. A new ring is inserted after a 7 day ring-free break.
• Women should be advised to check the presence of the ring regularly.
• The ring may be kept in during tampon use and sexual intercourse (but may be removed for no more than 3 hours if intercourse is uncomfortable with the ring in situ).
• The ring can be removed by hooking the index finger under the ring or grasping it between the index and middle finger.

In depth

• Prior to dispensing, the combined vaginal ring should be stored in a refrigerator (2°C–8°C) for up to 36 months.
• After dispensing:
• The ring can be stored at room temperature, but should not be stored above 30°C.
• The ring should be inserted up to 4 months from the date of dispensing or the expiry date, whichever comes first.

In depth

• Review the woman no longer than 3 months after she starts to use the combined contraceptive vaginal ring, to ensure correct use and that there are no problems.
• Check that the woman is using the ring correctly and consistently.
• Check her knowledge of what to do if she is late removing the ring or late reinserting a new ring.
• Remind her about possible drug interactions.
• Check her blood pressure.
• Ask about headaches, especially migraine, and any new risk factors — see UK Medical Eligibility Criteria.
• Address any issues or problems she might have, such as unscheduled bleeding.
• Depending on the woman's wishes and anticipated use of the ring, repeat scripts may be arranged for up to a year following this. Note: due to the shelf life of the ring, it is recommended that women are supplied with up to 3 rings at a time, and each ring should be inserted within 4 months of the date of dispensing.
• Women with specific medical conditions including an observed rise in blood pressure using the ring may need more frequent follow-up.
• Advise the woman that she should return at any time if she has any problems, including any new headache symptoms.

In depth

Lengthened ring use

• If the ring has been left in place for up to 4 weeks (rather than the recommended 3 weeks), contraceptive efficacy is not reduced. Advise the woman to remove the ring and insert a new ring after one ring-free week.
• If the ring has been left in place for more than 4 weeks (rather than the recommended 3 weeks), contraceptive efficacy may be reduced. Advise the woman to rule out pregnancy before inserting a new ring.
• If a woman has not used the ring as recommended and has no withdrawal bleed in the ring-free week, advise her to rule out pregnancy before inserting a new ring.

Lengthened ring-free interval

• Advise the woman to insert a new ring as soon as she remembers.
• Advise her to use additional barrier contraception for the next 7 days.
• If the woman had sexual intercourse in the ring-free interval, advise her to rule out pregnancy and consider emergency contraception (if appropriate) before inserting a new ring.

In depth

• 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, rinse the ring with cool to lukewarm water and reinsert it as soon as possible, within 3 hours.
• If the ring is expelled and left outside the vagina for more than 3 hours, the recommended action depends on the week of use.
• 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.
• 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.

In depth

• If the ring is found to be broken during use, advise the woman to remove it, reinsert a new ring as soon as possible, and use additional barrier contraception for the next 7 days.
• If it is suspected that unprotected sexual intercourse has taken place in the previous 5 days, emergency contraception should be considered — see the CKS topic on Contraception - emergency.

In depth

• If pregnancy occurs with a combined contraceptive vaginal ring in situ, the ring should be removed.

In depth

• If irregular bleeding (spotting or breakthrough bleeding) occurs after previously regular cycles while the ring has been used as recommended, then consider other non-hormonal causes. Consider excluding pregnancy and refer the woman according to clinical judgement.
• Some women do not experience a withdrawal bleed in the ring-free week.
• If the ring has been used as recommended, it is unlikely the woman is pregnant.
• If the ring has not been used as recommended prior to the first missed withdrawal bleed, or if there are two missed withdrawal bleeds, advise the woman that pregnancy should be ruled out before use of the ring is continued.

In depth

• The efficacy of the ring may be reduced by liver enzyme-inducing drugs, and non-liver enzyme-inducing antibiotics (excluding amoxicillin and doxycycline which do not appear to be affected).
• If a woman is taking a liver enzyme-inducing drug, advise her to use additional barrier contraception for the duration of treatment and for 28 days after its discontinuation, or choose another method of contraception. If the drug treatment runs beyond the 3 weeks of her cycle, advise her to insert the next ring immediately without a ring-free week.
• If a woman is taking non-liver enzyme-inducing antibiotics (excluding amoxicillin and doxycycline), advise her to use additional barrier contraception for the duration of treatment and for 7 days after their discontinuation. If the drug treatment runs beyond the 3 weeks of her cycle, advise her to insert the next ring immediately without a ring-free week.

In depth

The management of these problems is similar to that for women using a combined oral contraceptive (COC). For more information, see Diarrhoea or vomiting, unscheduled bleeding, surgery (on a COC). Note: diarrhoea and vomiting do not affect the bioavailability of the combined oral contraceptive patch.