Contraceptive Vaginal Ring

What is the contraceptive vaginal ring?

The contraceptive vaginal ring is an effective method of contraception. It is a thin, flexible, see-through ring which is just over 5 cm in diameter. It contains two hormones, an oestrogen and a progestogen, just like the combined oral contraceptive (COC) pill and the contraceptive patch. These hormones have effects on your body which prevent you from becoming pregnant. The only contraceptive vaginal ring currently available in the UK is the NuvaRing^®.

How does the contraceptive vaginal ring work?

The contraceptive vaginal ring contains two hormones: an oestrogen called ethinyl estradiol and a progestogen called etonogestrel. They are absorbed through the inside of your vagina. They work in three ways to prevent pregnancy:

• The main way that they stop you from getting pregnant is by changing the body's hormonal balance so that your ovaries do not produce an egg (ovulate).
• They cause the mucus made by the neck of the womb (cervix) to thicken and form a mucous plug. This makes it difficult for sperm to get through to the womb (uterus) to fertilise any egg that might have been released.
• They also make the lining of the womb thinner. This makes it less likely that a fertilised egg will be able to attach to the womb.

How effective is the contraceptive vaginal ring?

The contraceptive vaginal ring is effective. Between 3-90 women in 1,000 will become pregnant using this form of contraception for a year. It is about as effective as the COC pill.

How do I use the contraceptive vaginal ring?

When you first use the ring, you place a new ring into your vagina on the first day of your period. It is very flexible and you will be able to squeeze it easily in order to put it in. Find a position for the ring that is comfortable for you. The position of the ring does not affect how well it works. If you are unsure of how to do this, you can either look at the leaflet that comes with the packet or ask your practice nurse or GP for advice.

You can also insert the ring on Day 2-5 of your period and still rely on it straightaway (for example, so that you can start your new ring on a memorable day such as a Monday). If you put one in for the first time after Day 5 you cannot rely on it for your contraception for seven days and you should use extra precautions such as a condom.

• You leave the ring in place for three weeks. During this time you should check regularly that it is there.
• You remove the ring by hooking it out with your finger.
• Exactly one week later, put a new ring in - so on the same day of the week as you put it in the first time. (It is only for the first time you use it that you should start on the first day of your period.)

When you first start using the ring, write down the day of the week somewhere you will remember. That day of the week will always be your 'new ring day' every four weeks.

You can use tampons and have sex safely with it in place. If the ring falls out during sex, you must make sure you put it back within three hours.

Why would I choose the contraceptive vaginal ring?

• You don't have to remember to take a pill every day. You only need to remember to take your ring out after three weeks and put a new one in a week later.
• It doesn't interfere with sex.
• The hormones are absorbed through the vagina, rather than being swallowed as tablets and going through your gut. This means that your contraception is still effective even if you have an upset stomach - being sick (vomiting) or runny stools (diarrhoea).

Are there any side-effects or risks when using the contraceptive ring?

• Your partner may feel the ring during sex. Do not regularly remove the contraceptive vaginal ring or it may become less effective.
• You may be aware of the ring in your vagina. Some people may find this unpleasant.
• The most common side-effects are headaches, a sore vagina and vaginal discharge. Each of these side-effects occurs in about 1 in 20 women.
• Sometimes the ring falls out. (Wash it under a tap with cold or lukewarm water and put it back in if it has been out for less than three hours. If it has been out for longer, see the section below about what to do.)
• Sometimes a ring may break whilst in the vagina. This is rare. If this happens, you should remove the broken ring and insert a new one. Use extra contraception, such as condoms, for seven days.

Other more serious health risks are much rarer and happen as often as with the COC pill.

These serious but rare risks include:

• Blood clots in the blood vessels, lungs, heart or brain. It seems this risk may be slightly higher if you use the contraceptive vaginal ring rather than the COC pill. However, the risk is extremely small and much smaller than the risks of blood clots associated with being pregnant. If you or your close relatives have anything in the past which makes blood clots more likely, you would be advised by your doctor or nurse not to use the ring.
• There may be a very small increased risk of breast cancer and cancer of the neck of the womb (cervix.)

You can read more about risks of combined hormonal contraception (including the contraceptive patch as well as the ring and the combined pill). See the separate leaflet called The Combined Oral Contraceptive (COC) Pill.

What if I forget to change the ring?

If you forget to change your ring and it has been in place for:

• Up to four weeks: take it out as soon as you remember. Have one week without it, then replace with a new ring as normal.
• More than four weeks but less than five: remove it and put in a new ring straightaway, without a week's break.
• Five weeks or more: its contraceptive effect may have been reduced. You should check that you are not pregnant before putting in another one. If the test is negative, put in a new ring but use additional contraception such as condoms for seven days. You may also need emergency contraception. If you are not sure, ask your practice or family planning nurse or your doctor.

What if I forget to put the new ring in?

If you forget to insert a new ring after the seven-day break, you should put in a new ring as soon as you remember.

• If this is 48 hours or less after you were meant to put a new one in, you won't need to use any additional contraception.
• If it is more than 48 hours, you should also use additional contraception (such as a condom) for seven days. You might become pregnant if you have sex when you have forgotten to put a new ring in place, so talk with your doctor or nurse if you think you might need emergency contraception.

What if the ring comes out?

If the ring comes out for less than three hours, wash it and put it back. It will still be effective.

If the ring has been out for more than three hours in the first week:

• It may be less effective.
• Wash the ring and put it back as soon as you can.
• If it was out for more than 48 hours:
• Use extra precautions such as condoms for seven days.
• See your doctor or nurse if you have had sex without a condom in the previous week. You may also need emergency contraception.

If the ring has been out for more than three hours in the second or third week, throw the ring away and either:

• Put in a new ring and start a new three-week cycle; or
• Have a ring-free week and put in a new ring seven days after it came out. (Only take this option if the ring had been in place continuously for the previous seven days.)
• If it was out for more than 48 hours:
• Use extra precautions such as condoms for seven days.

If in doubt speak with your doctor or nurse. You should also see your doctor or nurse if you think you may need emergency contraception as above.

Can I use the ring continuously?

In surveys, most women would prefer not to have any periods or just to have occasional bleeding. Researchers have looked at how using the ring continuously (changing it every 21 days), without a week's break, might achieve this. In one study, women removed the ring on the fifth day of any bleeding if it had lasted more than four days. They then replaced it after a four-day break. It would seem that continuous use of the ring leads to many fewer episodes of bleeding but that they can be quite prolonged.

The ring can also be used for nine weeks continuously and then removed for the usual seven-day break during which a bleed will usually occur. This is called extended use.

The ring is not licensed for continuous or extended use but it would appear to be a safe option. It may have benefits both due to fewer periods and related symptoms, but also by making it more effective - it is less likely that you will forget to replace your ring if you are using it continuously. However, this has yet to be proven.

How do I store my ring?

The contraceptive vaginal ring should be stored at room temperature (not above 30°C) and once you have been given your ring you should use it within four months. This is why you will only be given a maximum of four rings at one time. Your ring is not biodegradable so, once you have finished with a ring, just put it in your normal household waste - do not flush it down the loo!

Who cannot use this method?

If you have been advised that you should not use the COC pill then you should also not use the contraceptive vaginal ring. In some cases this may be because you are at higher risk from blood clots (venous thromboembolism).

If any of the following apply to you, you should not use the contraceptive vaginal ring:

• If you have had a baby within the previous six weeks and are breastfeeding.
• If you are aged 35 or more and a regular smoker.
• High blood pressure (hypertension) that is not controlled with treatment.
• A venous thromboembolism in the past or one for which you are having treatment currently.
• If you are not very mobile for a long period of time - for example, if you are in a wheelchair or have your leg in a plaster cast.
• You had a baby less than three weeks previously.
• If you are obese - your body mass index (BMI) is over 35 kg/m².
• If you have a history of migraine associated with a change in your eyesight before the headaches (aura).
• If you have ever had a stroke.
• If you have ever had angina or a heart attack.
• If you have ever had problems with the circulation of your legs (peripheral arterial disease).
• If you have complications from type 1 diabetes or type 2 diabetes.
• If you have breast cancer.

You would also be at higher risk and probably advised not to use the ring other than in exceptional circumstances if the following apply:

• High blood pressure (hypertension) which is controlled on treatment.
• A family history of a venous thromboembolism in a first-degree relative (for example, sister, mother) who was aged under 45 years when it happened.
• You have gallstones.
• If you are on certain medications, particularly for epilepsy.

If you have a vaginal prolapse, you may find it difficult to keep the ring in place. If you have a problem with constipation, you may also find it difficult to keep the ring in place.

This is not a complete list of all the conditions which make it advisable to avoid use of the contraceptive vaginal ring. As long as your doctor or nurse is aware of all your medical history, and your family history, they will be able to advise if it is safe for you.

Who can advise me?

Your GP, practice nurse, family planning clinic and pharmacist are good sources of information if you have any queries.