Can Nuvaring cause wrinkles? Transition from progestin contraception

Novaring

Compound

1 vaginal ring Nuvaring contains:
Etonogestrel – 11.7 mg;
Ethinyl estradiol – 2.7 mg;
Additional ingredients.

Pharmacological action

Nuvaring – hormonal contraceptive drug in the form vaginal ring. Nuvaring contains an estrogen and a progestogen component (ethinyl estradiol and etonogestrel, respectively). When using the drug Nuvaring, there is a delay in ovulation, some changes in the endometrium of the uterus, as well as an increase in the viscosity of cervical mucus, which makes pregnancy impossible.
The Pearl index for the drug Nuvaring is 0.765.
In addition to the contraceptive effect, the drug also helps to normalize menstrual cycle, reducing the severity of algodismenorrhea and premenstrual syndrome, as well as reducing the intensity of bleeding during menstruation, which can lead to a reduced risk of developing iron deficiency anemia.

When using the Novaring vaginal ring, ethinyl estradiol and etonogestrel are well absorbed into the systemic circulation through the vaginal mucosa. Peak plasma concentrations of etonogestrel when using a vaginal ring are achieved within 1 week, ethinyl estradiol - 3 days. The absolute bioavailability of etonogestrel when using the drug Nuvaring is 100% (which exceeds the absolute bioavailability with orally). The absolute bioavailability of ethinyl estradiol when using the vaginal ring corresponds to that when taken orally.

Etonogestrel and ethinyl estradiol are metabolized in the body and excreted primarily as metabolites by the kidneys and bile. Ethinyl estradiol and etonogestrel are eliminated from the body in two phases, the second phase is characterized by a half-life for etonogestrel of about 29 hours, for ethinyl estradiol of about 34 hours. The half-life of etonogestrel metabolites reaches 6 days, ethinyl estradiol metabolites – 1.5 days.
When using a vaginal ring therapeutic doses ethinyl estradiol and etonogestrel in plasma are maintained for 3 weeks, after which they are gradually reduced.

Indications for use

Nuvaring is used as a contraceptive.

Directions for use

The Nuvaring ring is intended for intravaginal use. You can insert the ring yourself; to do this, you need to choose a comfortable position (sitting or standing, raising one leg, or lying down). To insert, the ring is squeezed and inserted into the vagina. The exact position of the ring in the vagina is not of great importance for the contraceptive effect, but it should be conveniently placed so as not to cause discomfort or difficulties during sexual intercourse. After insertion, the ring should remain in the vagina for 3 weeks. If the ring is accidentally removed from the vagina (for example, when using a tampon), it should not be rinsed. hot water and immediately enter it back. After 3 weeks (on the same day of the week when the ring was inserted), the ring should be removed from the vagina. 7 days after removal of the previous ring, if the woman still needs contraception, the following is administered Nuvaring ring. During the 7-day break, the woman should begin menstrual-like bleeding (as a rule, bleeding begins 2-3 days after removal of the Nuvaring ring). The next Nuvaring ring is administered regardless of whether menstrual bleeding has ended or not.

If there is a risk of pregnancy, pregnancy should be ruled out before using the Nuvaring ring.
If a woman did not use hormonal contraceptives in the previous cycle, the Nuvaring ring should be started to be used during the first 5 days of the cycle (the first day of the cycle is the day the menstruation begins). During the first 7 days, in this case, you should additionally use a condom or other barrier method of contraception.
If a woman took oral contraceptives in the previous cycle, the Nuvaring ring should be started on the first day after a 7-day break or the day after taking the last placebo pill.

If a woman used minipills or other progestogen-only medications (including progestogen-only intrauterine devices) in a previous cycle, use of the Nuvaring ring should begin on the day the last dose of progestogens was received (the day the next injection would have been given progestogens, or on the day of removal intrauterine device with progestogens). When switching from contraceptives that contain only progestogens to the Nuvaring ring, you should use a barrier method of contraception for the first 7 days.
After an abortion performed in the first trimester, the Nuvaring ring can be used immediately after the abortion (in this case there is no need to additional method contraception).
After childbirth, miscarriage or abortion in the second trimester, it is recommended to start using the Nuvaring ring within the fourth week after childbirth or abortion. If using the Nuvaring ring is started later, you should additionally use a condom or other barrier method of contraception for the first 7 days.

If after a 7-day break a woman has forgotten to insert the Nuvaring ring, it should be administered as soon as possible. During the first 7 days, in this case, you should additionally use a condom or other barrier method of contraception.
If the ring is accidentally removed, contraceptive effectiveness is reduced if the Nuvaring ring is outside the vagina for more than 3 hours. The ring should be inserted back into the vagina as soon as possible, but if the break was more than 3 hours, additional barrier contraception should be used over the next 7 days. If these 7 days fall in the third week of using the Nuvaring drug, the ring must remain in the vagina for more than 3 weeks (counting starts from the moment the ring is first inserted), the next ring in this case is inserted a day after the previous one is removed.

If a woman forgot to remove the Nuvaring ring in time, it should be taken into account that its effectiveness remains for 4 weeks after administration. If the ring was not removed on time, it should be removed as soon as the woman remembers it. In this case, a new ring is inserted 1 day after the previous one is removed. If the Nuvaring ring has been in the vagina for more than 4 weeks, its effectiveness is reduced and pregnancy should be excluded before using a new one.
If during the 7-day break between the use of the drug Nuvaring there is no development of menstrual-like bleeding, pregnancy should be excluded before introducing a new ring.
For deferment menstrual bleeding a woman can insert the next ring without a 7-day break. During the use of the second ring, in this case, minor bleeding may develop. In subsequent cycles, rings should be administered as recommended, taking 7-day breaks.

To change the time of menstrual bleeding, a woman can shorten the interval between using the drug Nuvaring for as many days as it is necessary to postpone menstruation. The shorter the break, the higher the chance that there will be no menstrual bleeding, but minor bleeding will appear during the cycle. spotting.
The used Nuvaring ring should be bagged and disposed of with household waste in such a way as to avoid accidental contact of the ring with other people.

Side effects

Nuvaring is generally well tolerated by patients. There is information about in some cases the development of such undesirable effects caused by the active components of the drug Nuvaring:
From the nervous system: emotional lability, headache, migraine and migraine-like headache, depression, dizziness, causeless anxiety, increased fatigue.

From the reproductive system: decreased libido, enlarged and tense breasts, dysmenorrhea, vaginal discharge, cervicitis, vaginitis, problems associated with sexual intercourse, which are caused by the location of the ring.
From the digestive system and liver: pain in the epigastric region, stool disorders, nausea, vomiting, changes in body weight.
Allergic reactions: urticaria, itchy skin, Quincke's edema.
Others: cystitis.

Contraindications

Nuvaring should not be used in women with intolerance active ingredients vaginal ring.
The drug Nuvaring is not prescribed to patients with thrombosis, thromboembolism and high risk the development of these conditions (including a history), migraine with neurological manifestations, diabetes mellitus with vascular complications, pancreatitis with hypertriglyceridemia (including a history), as well as liver dysfunction.
Nuvaring is not recommended for use in patients with liver tumors (including a history), hormone-dependent malignant tumors (including suspected ones), vaginal bleeding of unknown origin, as well as suspected pregnancy.

Caution should be exercised when prescribing Nuvaring to patients suffering from diabetes mellitus, arterial hypertension, obesity, heart valve disease and atrial fibrillation, dyslipoproteinemia, diseases of the hepatobiliary system, sickle cell anemia, ulcerative colitis and Crohn's disease.
Caution should be exercised when recommending Nuvaring to patients with hemolytic uremic syndrome, epilepsy, systemic lupus erythematosus, uterine fibroids, fibrocystic mastopathy, as well as chloasma and congenital hyperbilirubinemia.

Women over the age of 35 who smoke, as well as patients with prolonged immobilization, should use Nuvaring with caution.
It is recommended to prescribe Nuvaring with caution to patients with conditions that may make it difficult to insert the ring or lead to its loss (including patients with cervical prolapse, hernia bladder or rectum, severe stool disorders).

Pregnancy

Nuvaring is not used during pregnancy, or if pregnancy is suspected. Before using a new ring, if there was a risk of pregnancy in the previous cycle ( misuse drug Nuvaring, taking drugs that reduce the effectiveness of the Nuvaring ring), pregnancy should be excluded.
Nuvaring during lactation can be used only after refusal breastfeeding.

Drug interactions

Drugs that induce microsomal liver enzymes, when used in combination with Nuvaring, reduce its contraceptive effect. When using the Nuvaring ring in combination with phenobarbital, phenytoin, rifampicin, primidone, carbamazepine, topiramate, oxcarbazepine, ritonavir, felbamate, St. John's wort and griseofulvin, a barrier method of contraception should be additionally used (if these drugs are taken for more than 2 weeks, a barrier method of contraception should be used for entire cycle, as well as during the next menstrual cycle).

The effectiveness of Nuvaring may be reduced when combined with tetracyclines and penicillins; it is recommended to use a barrier method of contraception if the combined use of these drugs is necessary.

Overdose

When using excessive doses of Nuvaring, patients may develop vomiting, nausea and bleeding from the vagina.
There is no specific antidote. If symptoms of overdose develop, you should consult a doctor who will decide on the possibility of further use of the drug Nuvaring and prescribe symptomatic treatment.

Release form

1 vaginal ring with an external diameter of 54 mm and an internal diameter of 4 mm Nuvaring in an aluminum foil bag, 1 package is included in a cardboard box.
The packaging of Nuvaring is sealed and can be resealed.

Storage conditions

It is recommended to store Nuvaring in its original packaging at a temperature of 2 to 8 degrees Celsius. The drug is suitable for use for 3 years after release.
Information about the drug is provided for informational purposes only and should not be used as a guide to self-medication. Only a doctor can decide to prescribe the drug, as well as determine the dose and methods of its use.

Ring NuvaRing — hormonal drug, which has a high contraceptive effect and does not cause negative consequences for the body. The instructions for use characterize it as a reliable method of protection.

It is not fussy to use, since it does not require the daily participation of a woman, acting independently. How exactly is this level of protection against unwanted conception achieved, and in what situations should it be preferred?

Nuvaring ring, the instructions for use of which describe in detail the rules of use, is highly effective birth control contraceptive new generation. Artificial material, from which the ring is made, is also used for breast enlargement and in the manufacture of implants.

This is a translucent, almost colorless rim, 6 cm in diameter, which reliably protects the egg from fertilization by sperm and the onset of conception. The material from which the drug is made is hypoallergenic, so a negative reaction to it occurs extremely rarely.

Composition and principle of action

The instructions for the NuvaRing ring describe in detail the active substance and mechanism of action. Inside the ring are ethinyl estradiol and etonogestrel, which are released from their shell every day in strictly limited doses. Due to the fact that there are many vessels in the vagina, the active substance quickly penetrates the blood and begins to act.

Birth control pills work in the same way, when taken the substance is absorbed through the stomach, and not through the walls of the vagina.

On female body NuvaRing has the following effects:

1. Suppresses the onset of ovulation.
2. Does not allow the hormonal system to function.
3. Promotes education thick mucus in the cervix, preventing sperm from penetrating and fertilizing the egg.

These processes can be reversed if you stop removing the ring from the body and wait for the cycle to normalize.

Advantages of the method

In addition to the reliability of this type of contraception, the NuvaRing ring has other positive aspects:

1. Low doses of hormones that a woman receives daily while using the ring. According to researchers, it releases almost a third less ethinyl estradiol than oral contraceptives.
2. A woman does not need to think about taking contraceptives every day, since the drug works independently of her, releasing the required amount of the active substance.
3. It makes it easy to adjust your monthly cycle, namely, delaying or prolonging the onset of menstrual bleeding.
4. Like any hormonal drug, NuvaRing has a beneficial effect on appearance– improves skin, hair and nails, reduces discomfort during menstruation and pain.

Disadvantages of the method

The main disadvantages of using a contraceptive ring are the presence of an impressive list of contraindications and side effects, as well as the need to strictly adhere to the regimen of using the drug.

But the disadvantages do not end there:

1. The NuvaRing cannot protect a woman from sexually transmitted diseases, such as AIDS and syphilis. The same can be said about all hormonal contraceptives.
2. Additionally, if a woman is susceptible to infection, the presence of a foreign object in the vagina can increase inflammation and increase the amount of discharge.
3. Due to the fact that the ring can move and even be removed from the vagina on its own, there is a need to periodically check its presence in order to prevent sperm from fertilizing the egg.
4. This method of contraception is psychologically unusual for women, and therefore often causes mistrust in its contraceptive properties.

Technique of use

You can use the NuvaRing ring only after fully reading the instructions and consulting with a gynecologist. You should not prescribe the use of this contraceptive yourself, as it is difficult to take into account all the nuances known only to a professional.

When the first period occurs, you can inject the drug into the vagina, and the procedure should be as follows:

1. Wash your hands.
2. Take a comfortable position that allows access to the vagina and allows you to completely relax, for example, lie on the sofa.
3. Open the package and remove the ring from the aluminum wrapper.
4. Flatten it with two fingers and insert the ring deeply into the vagina, adhering to the back wall.

The whole process does not take much time and is very similar to inserting a tampon when menstruation occurs. There should not be any pain, therefore, if you feel discomfort, you should immediately remove the drug and consult a doctor. Elastic ring NuvaRing, in case correct application, should stick to the walls of the vagina and be fixed on them.

After three weeks of use, the contraceptive should be removed. This needs to be done correctly, although there is nothing complicated in the process.

You need to again take a comfortable position and pick up the ring with your finger to carefully remove it from the body. This item can no longer be reused, so it can be disposed of. Next, the girl can expect bleeding, which should begin within the next 7 days. A new ring should be inserted 8 days after the previous one is removed.

Use if hormonal contraceptives were not used in the previous cycle

The NuvaRing ring can be administered already on the first day of the cycle at the initial signs of bleeding in order to protect yourself as much as possible from conception. If necessary, you can delay using the ring for 2-5 days if you turn to alternative methods of protection.

Switching from combined hormonal contraceptives

If desired, a woman can change the method of contraception and choose the NuvaRing ring instead of combined hormonal drugs. The instructions for use do not exclude this possibility if the woman followed the gynecologist’s instructions and did not miss taking pills.

Switching from drugs containing only progestogen

Mini-pills can also be easily replaced with NuvaRing. Moreover, the transition can be made on any day of the cycle by instantly replacing the implant or IUD with a ring. When using injections to prevent conception, you should not take breaks, but replace them after the final injection.

After this, it is better to resort to using condoms for a week due to possible reduction protective effect of the ring.

After an abortion in the first trimester

By using the NuvaRing ring after an early abortion, the instructions clearly describe this situation, you do not have to resort to alternative methods of protection against conception. An exception may be medical indications, in which a woman is allowed to delay the insertion of the ring for up to 5 days.

After childbirth or after an abortion in the second trimester

More serious abortion performed surgical method By medical indications, or childbirth requires a more delicate approach in further protection. NuvaRing should be used only after a month if the woman is not breastfeeding her newborn.

In case of delaying contraception and using the ring for more late dates, you should use condoms to protect yourself as much as possible from conception. In addition, you need to make sure that you are not pregnant. It is necessary to continue using barrier methods of protection for 7 days after inserting the ring.

Use during pregnancy and breastfeeding

Due to the fact that the NuvaRing ring is a hormonal drug intended to prevent pregnancy, its use during this period is strictly prohibited. Although studies of the drug have not been conducted among women expecting to give birth, there is no need to risk the health of the baby.

In addition, once pregnancy has already occurred, there is no need for contraception. The same cannot be said about the lactation period, which is also not recommended to be combined with the use of hormonal contraceptives. This is due to the fact that the active substance contained in the ring can change its composition breast milk, or reduce its volume.

Break in use

Violation of the contraceptive regimen prescribed by the gynecologist can lead to conception. Before using the NuvaRing ring after a break, the instructions provided by the manufacturer advise you to make sure there is no pregnancy.

If fertilization of the egg has not occurred, the drug should be installed as soon as possible, while simultaneously using alternative ways contraception. But a break does not always happen due to the fault of a woman who simply got lost in the dates.

The NuvaRing ring tends to involuntarily move into the vagina and even be removed from it. Then it is urgently necessary to return it to its place. If the contraceptive was absent from the vagina for no more than 3 hours, then there is no need to be afraid of conception. Otherwise, it is better to play it safe and resort to condoms or other barrier methods.

Extended use

If NuvaRing was used longer than prescribed, but not longer than a month, then contraceptive effect will remain sufficient to prevent conception. The woman needs to take the prescribed week break and use the following drug.

Scheme for using the NovaRing contraceptive ring.

After 4 weeks of use, the contraceptive effect of NuvaRing decreases, therefore, before inserting a new ring, you need to take a pregnancy test or consult a doctor to establish the fact that you are not pregnant.

Menstruation and bleeding during use

Bleeding during contraception with this hormonal drug is considered normal. Most often, menstruation begins immediately after the ring is removed and stops with the introduction of a new contraceptive. Less often, bleeding does not start at all, and this is also not a deviation, provided that all recommendations are followed.

Repeated absence of menstruation requires the intervention of a gynecologist, as this may mean pregnancy. However, when using the NuvaRing ring, the instructions require strict monitoring of the body’s condition, since severe bleeding must be observed by the attending gynecologist.

Cancellation of NuvaRing

A woman can refuse protection with NuvaRing at any time, since this process does not require special training. If necessary, the drug can be safely removed without waiting for 21 days of use.

Pregnancy after stopping the contraceptive ring

Refusal hormonal contraception leads to the cessation of effects on the woman’s body, and NuvaRing is no exception. Conception can occur as early as 4-5 weeks after the contraceptive ring is removed.

Drug interactions

Parallel use of the NuvaRing ring with others medications, may lead to a decrease in contraceptive effect, as the instructions warn about.

Medicines that should not be combined with hormonal contraception:

1. Drugs, in large quantities excreted by the liver, leading to hepatic metabolism. This refers to medications such as barbitures, carbamazepine, phenytoin, rifampicin, and some other medications containing St. John's wort. When undergoing therapy with these drugs, it is better to resort to alternative methods of contraception without removing the ring from the vagina.
2. Antibiotics also lead to a decrease in the contraceptive effect, as they have a great effect on the active substance of NuvaRing. When taking these drugs, with the exception of doxycycline and amoxicillin, you should use barrier contraceptives during treatment and for a week after the end of the course.

Protection with hormonal ring may also affect biochemical parameters some organs and change the composition of the blood. If during contraception a woman needs to undergo medical commission, the attending physician should be aware of the use of the NuvaRing ring.

Side effects

A negative reaction to the drug is extremely rare, but not completely excluded. Side effects associated with the use of NuvaRing rings usually do not require immediate attention. medical care because they pass on their own.

TO side effects include:

1. Intoxication – nausea, diarrhea, and sometimes vomiting.
2. dizziness, constant anxiety, changeable mood, pain in the head, as a result of the effect on the nervous system.
3. Weight gain, breast hardening, decreased libido.
4. Cystitis.
5. Minor discharge, vaginitis.

In addition, a woman may be bothered by the sensation of a foreign object in the vagina, as well as spontaneous removal of the ring.

Contraindications for use and use with caution

Not everyone is recommended to use the NuvaRing ring, since it has quite a lot of prohibitions and contraindications.

• Hormone-dependent malignant tumors.
• Vaginal bleeding that occurs for unknown reasons.
• Blood disorders such as thrombosis or bleeding disorders.
• Pregnancy and lactation.
• Severe liver pathologies, including tumors.
• Inflammatory processes in the vagina - vaginitis, colpitis.
• Allergies to contraceptive components.

Careful use of the product is possible for:

• varicose veins;
• heart disease;
• autoimmune diseases;
• when the walls of the female genital organ droop or fall out;
• cholelithiasis;
• smoking.

It is necessary to stop using NuvaRing before the proposed surgery.

Conditions and shelf life

To prevent the drug from losing its contraceptive properties, it must be kept at 2-8 °C, then the NuvaRing ring will not lose its properties for 3 years from the date of release. The best place for this there will be a regular refrigerator compartment, where the required temperature is maintained.

In addition, the contraceptive ring should be protected from children's attention, since if it enters the body of a minor child, it can negatively affect the development of the baby. After the expiration date, it is strictly forbidden to use the drug for its intended purpose.

Where to buy and price

The NuvaRing ring is sold in free access, so you can find it at any pharmacy. A large selection of drugs is offered by online portals for the sale of medicines. This makes it possible to resort to the use of NuvaRing in the most remote corners of the country, thanks to well-established logistics and courier delivery. On average, the price of one ring ranges from 600 to 1000 rubles.

Packages of the NuvaRing ring containing 3 contraceptives will cost from 1300 to 1800 rubles.

Every woman will find her own positive aspects of this method of contraception, because the convenience and effectiveness of the NuvaRing ring are obvious. Before deciding to use a hormonal drug, you should study the instructions and also consult a gynecologist.

Video about the NuvaRing ring, its effectiveness and rules of use

Instructions for use of the NuvaRing ring:

Expert opinion about the Nuvaring ring:

Name:

Novaring

Pharmacological
action:

Combined hormonal contraceptive drug, containing etonogestrel and ethinyl estradiol.
Etonogestrel is a progestogen (19-nortestosterone derivative) that binds with high affinity to progesterone receptors in target organs. Ethinyl estradiol is an estrogen and is widely used in the production of contraceptives.
The contraceptive effect of the drug NuvaRing is due to a combination of various factors, the most important of which is the suppression of ovulation.

Efficiency
In clinical studies, it was found that the Pearl index (an indicator reflecting the frequency of pregnancy in 100 women during 1 year of contraception) in women aged 18 to 40 years for the drug NuvaRing was 0.96 (95% CI: 0.64-1.39) and 0.64 (95% CI: 0.35-1.07) at statistical analysis all randomized participants (ITT analysis) and analysis of study participants who completed them according to the protocol (PP analysis), respectively. These values ​​were similar to the Pearl index values ​​obtained in comparative studies of combined oral contraceptives (COCs) containing levonorgestrel/ethinyl estradiol (0.150/0.030 mg) or drospirenone/ethinyl estradiol (3/0.30 mg).
With the use of the drug NuvaRing, the cycle becomes more regular, the pain and intensity of menstrual-like bleeding decreases, which helps reduce the incidence of iron deficiency conditions. There is evidence of a reduction in the risk of endometrial and ovarian cancer with the use of the drug. In addition, high-dose COCs (0.05 mg ethinyl estradiol) reduce the risk of developing ovarian cysts, pelvic inflammatory diseases, benign changes in the mammary glands and ectopic pregnancy. It is not entirely clear whether low-dose hormonal contraceptives offer similar benefits.

Nature of bleeding
A comparison of bleeding patterns over one year in 1000 women using the drug NuvaRing and COCs containing levonorgestrel/ethinyl estradiol (0.150/0.030 mg) showed a significant reduction in the frequency of breakthrough bleeding or spotting when using the drug NuvaRing compared with COCs. In addition, the frequency of cases where bleeding occurred only during a break in the use of the drug was significantly higher among women using the drug NuvaRing.
Effect on bone mineral density
A comparative two-year study of the effect of the drug NuvaRing (n=76) and a non-hormonal intrauterine device (n=31) did not reveal any effect on mineral density bone tissue in women.
Children
The safety and effectiveness of NuvaRing for adolescents under 18 years of age has not been studied.

Pharmacokinetics
Etonogestrel
Suction
Etonogestrel, released from the NuvaRing vaginal ring, is rapidly absorbed through the vaginal mucosa. Cmax of etonogestrel, approximately 1700 pg/ml, is achieved approximately 1 week after ring insertion. Serum concentrations vary over a small range and decrease slowly to approximately 1600 pg/mL after 1 week, 1500 pg/mL after 2 weeks, and 1400 pg/mL after 3 weeks of use. Absolute bioavailability is about 100%, which exceeds the bioavailability of etonogestrel when taken orally. Based on the results of measurements of etonogestrel concentrations in the cervix and inside the uterus in women using the drug NuvaRing and women
using oral contraceptives containing 0.150 mg desogestrel and 0.020 mg ethinyl estradiol, the observed etonogestrel concentrations were comparable.

Distribution
Etonogestrel binds to serum albumin and sex hormone binding globulin (SHBG). Vd of etonogestrel 2.3 l/kg.
Metabolism
Etonogestrel is metabolized in the liver to form sulfate and glucuronide conjugates. Serum clearance is about 3.5 l/h. No direct interaction with ethinyl estradiol has been identified.
Removal
The decrease in serum etonogestrel concentrations is biphasic. T1/2 of the β-phase is about 29 hours. Etonogestrel and its metabolites are excreted in urine and bile in a ratio of 1.7:1. T1/2 of metabolites is approximately 6 days.

Ethinyl estradiol
Suction
Ethinyl estradiol released from NuvaRing is rapidly absorbed through the vaginal mucosa. Cmax of approximately 35 pg/ml is achieved 3 days after ring insertion and decreases to 19 pg/ml after 1 week, to 18 pg/ml after 2 weeks and 18 pg/ml after 3 weeks of use.
Absolute bioavailability is approximately 56% and is comparable to that of oral ethinyl estradiol. Based on the results of measurements of ethinyl estradiol concentrations in the cervix and inside the uterus in women using the drug NuvaRing and women using oral contraceptives containing 0.150 mg of desogestrel and 0.020 mg of ethinyl estradiol, the observed values ​​of ethinyl estradiol concentrations were comparable.
Ethinyl estradiol concentrations were studied in a comparative randomized study of NovaRing (daily vaginal release of ethinyl estradiol 0.015 mg), transdermal patch (norelgestromin/ethinyl estradiol; daily release of ethinyl estradiol 0.020 mg) and COC (levonorgestrel/ethinyl estradiol; daily release of ethinyl estradiol 0.015 mg). .030 mg) during one cycle in healthy women.
Systemic exposure to ethinyl estradiol over a month (AUC0-∞) for the NuvaRing drug was statistically significantly lower than for the patch and COCs, and amounted to 10.9, 37.4 and 22.5 ngch/ml, respectively.

Distribution
Ethinyl estradiol binds to serum albumin. Vd is about 15 l/kg.
Metabolism
Ethinyl estradiol is metabolized by aromatic hydroxylation followed by methylation to form a variety of hydroxylated and methoxylated metabolites, which are present both in the free state and as glucuronide and sulfate conjugates. Serum clearance is about 3.5 l/h.
Removal
The decrease in serum ethinyl estradiol concentration is biphasic. T1/2 of the β phase is characterized by large individual differences, and, on average, is about 34 hours. Ethinyl estradiol is not excreted unchanged; its metabolites are excreted in urine and bile in a ratio of 1.3:1. T1/2 of metabolites is about 1.5 days.

Special patient groups
Children
The pharmacokinetics of NovaRing in healthy adolescent girls under 18 years of age who have already menstruated have not been studied.
Renal dysfunction
The effect of kidney disease on the pharmacokinetics of NuvaRing has not been studied.
Liver dysfunction
The effect of liver diseases on the pharmacokinetics of NuvaRing has not been studied.
However, in patients with impaired liver function, the metabolism of sex hormones may deteriorate.
Ethnic groups
The pharmacokinetics of the drug in representatives of ethnic groups has not been specifically studied.

Indications for
application:

Nuvaring is used as a contraceptive.

Directions for use:

The Nuvaring ring is intended for intravaginal use..
You can insert the ring yourself; to do this, you need to choose a comfortable position (sitting or standing, raising one leg, or lying down).
To insert, the ring is squeezed and inserted into the vagina.
The exact position of the ring in the vagina is not of great importance for the contraceptive effect, but it should be conveniently placed so as not to cause discomfort or difficulties during sexual intercourse.
After insertion, the ring should remain in the vagina for 3 weeks. If the ring is accidentally removed from the vagina (for example, when using a tampon), it should be rinsed with cool water and immediately reinserted.
After 3 weeks (on the same day of the week when the ring was inserted), the ring should be removed from the vagina. 7 days after removal of the previous ring, if the woman still needs contraception, the next Nuvaring ring is administered.
During the 7-day break, the woman should begin menstrual-like bleeding (as a rule, bleeding begins 2-3 days after removal of the Nuvaring ring).
The next Nuvaring ring is administered regardless of whether menstrual bleeding has ended or not.

If there is a risk of pregnancy, before starting to use the Nuvaring ring, pregnancy should be ruled out.
If a woman did not use hormonal contraceptives in the previous cycle, the Nuvaring ring should be started to be used during the first 5 days of the cycle (the first day of the cycle is the day the menstruation begins). During the first 7 days, in this case, you should additionally use a condom or other barrier method of contraception.
If a woman took oral contraceptives in the previous cycle, the Nuvaring ring should be started on the first day after a 7-day break or the day after taking the last placebo pill.

If the woman used mini-pills or other drugs in the previous cycle containing only progestogens (including progestogen-containing intrauterine devices), use of the Nuvaring ring should be started on the day the last dose of progestogens was received (the day the next progestogen injection would have been given, or the day the progestogen-containing intrauterine device was removed).
When switching from contraceptives that contain only progestogens to the Nuvaring ring, you should use a barrier method of contraception for the first 7 days.
After an abortion, performed in the first trimester, the Nuvaring ring can be used immediately after an abortion (in this case, an additional method of contraception is not required).
After childbirth, miscarriage or abortion in the second trimester It is recommended to start using the Nuvaring ring within the fourth week after childbirth or abortion.
If using the Nuvaring ring is started later, you should additionally use a condom or other barrier method of contraception for the first 7 days.

If after a 7-day break a woman forgot to insert the Nuvaring ring, it should be introduced as early as possible. During the first 7 days, in this case, you should additionally use a condom or other barrier method of contraception.
If the ring is accidentally removed, contraceptive effectiveness is reduced if the Nuvaring ring is outside the vagina for more than 3 hours. The ring should be inserted back into the vagina as soon as possible, but if the break was more than 3 hours, additional barrier contraception should be used over the next 7 days.
If these 7 days fall in the third week of using the Nuvaring drug, the ring must remain in the vagina for more than 3 weeks (counting starts from the moment the ring is first inserted), the next ring in this case is inserted a day after the previous one is removed.

If a woman forgot to remove the Nuvaring ring in time, it should be taken into account that its effectiveness remains for 4 weeks after administration.
If the ring was not removed on time, it should be removed as soon as the woman remembers it. In this case, a new ring is inserted 1 day after the previous one is removed. If the Nuvaring ring has been in the vagina for more than 4 weeks, its effectiveness is reduced and pregnancy should be excluded before using a new one.
If during the 7-day break between the use of the drug Nuvaring there is no development of menstrual-like bleeding, pregnancy should be excluded before introducing a new ring.
To delay menstrual bleeding a woman can insert the next ring without a 7-day break.
During the use of the second ring, in this case, minor bleeding may develop. In subsequent cycles, rings should be administered as recommended, taking 7-day breaks.

To change menstrual bleeding time a woman can reduce the break between using the drug Nuvaring by as many days as necessary to postpone her menstruation.
The shorter the break, the higher the chance that there will be no menstrual bleeding, but minor spotting will appear during the cycle.
The used Nuvaring ring should be bagged and disposed of with household waste in such a way as to avoid accidental contact of the ring with other people.

Side effects:

Nuvaring is generally well tolerated by patients.
There is evidence of isolated cases of the development of such undesirable effects caused by the active components of the drug Nuvaring:
- from the nervous system: emotional lability, headache, migraine and migraine-like headache, depression, dizziness, causeless anxiety, increased fatigue;
-from the reproductive system: decreased libido, enlarged and tense breasts, dysmenorrhea, vaginal discharge, cervicitis, vaginitis, problems associated with sexual intercourse, which are caused by the location of the ring;
- from the digestive system and liver: pain in the epigastric region, stool disorders, nausea, vomiting, changes in body weight;
- allergic reactions : urticaria, skin itching, Quincke's edema;
-other: cystitis.

Contraindications:

Venous thrombosis (including a history), including thromboembolism;
- arterial thrombosis (including history), including disorders cerebral circulation, myocardial infarction and/or precursors of thrombosis, including angina pectoris, transient ischemic attack;
- heart defects with thrombogenic complications;
- predisposition to the development of venous or arterial thrombosis, including hereditary diseases: resistance to activated protein C, antithrombin III deficiency, protein C deficiency, protein S deficiency, hyperhomocysteinemia and antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant);
- migraine with a history of focal neurological symptoms;
- diabetes mellitus with vascular damage;
- pronounced or multiple risk factors for venous or arterial thrombosis;
- pancreatitis (including a history), in combination with severe hypertriglyceridemia;
- severe liver diseases, until normalization of liver function indicators;
- liver tumors, malignant or benign (including in history);
- established or suspected hormone-dependent malignant tumors (for example, genital organs or breast);
- vaginal bleeding of unknown etiology;
- pregnancy (including suspected);
- hypersensitivity to any of the active or excipients of the drug NuvaRing.
If any of the above conditions occur, you should immediately stop using the drug.

Prescribe with caution the drug if you have any of the diseases, conditions or risk factors listed below; in such cases, the doctor must carefully weigh the benefit-risk ratio of using the drug NuvaRing:
- presence of diseases in the family history ( venous thrombosis and embolism and/or arterial thrombosis in brothers/sisters at any age or in parents at a relatively early age;
- long-term immobilization, major surgical interventions, any surgical interventions on lower limbs or serious injury;

- thrombophlebitis of superficial veins;
- smoking (especially in women over 35 years old);
- dislipoproteinemia;
- heart valve disease;
- atrial fibrillation;
- arterial hypertension;
- diabetes mellitus;
- sharp or chronic disorders liver functions;
- jaundice and/or itching caused by cholestasis;
- cholelithiasis;
- porphyria;
- systemic lupus erythematosus;
- hemolytic-uremic syndrome;
- Sydenham's chorea (minor chorea);
- hearing loss due to otosclerosis;
- (hereditary) angioedema;
- chronic inflammatory diseases intestines (Crohn's disease and ulcerative colitis);
- sickle cell anemia;
- chloasma;
- conditions that make it difficult to use a vaginal ring: cervical prolapse, bladder hernia, rectal hernia, severe chronic constipation.
In case of exacerbation of diseases, deterioration of condition or occurrence of any of listed conditions For the first time, you should consult a doctor to decide on the possibility of further use of the drug NuvaRing.

If you have any of the diseases, conditions or risk factors listed below, you should evaluate the benefits of using the drug NuvaRing and possible risks for each individual woman even before she starts using the drug NuvaRing.
In case of exacerbation of diseases, deterioration of the condition, or the occurrence of any of the conditions listed below for the first time, a woman should consult a doctor to decide on the possibility of further use of the drug NuvaRing.

Circulatory disorders
The use of hormonal contraceptives may be associated with the development of venous thrombosis (deep vein thrombosis and pulmonary embolism) and arterial thrombosis, as well as associated complications, sometimes fatal.
The use of any COC increases the risk of developing venous thromboembolism (VTE) compared to the risk of VTE in patients not using COCs. The greatest risk of developing VTE is observed in the first year of COC use. Data from a large prospective cohort study of the safety of various COCs suggests that the greatest increase in risk, compared with the risk level in women who do not use COCs, is observed in the first 6 months after starting COC use or resuming their use after a break (4 weeks or more). U non-pregnant women In women who do not use oral contraceptives, the risk of developing VTE ranges from 1 to 5 cases per 10,000 woman-years (WY).

In women using oral contraceptives, the risk of developing VTE ranges from 3 to 9 cases per 10,000 women. The increase in risk occurs to a lesser extent than in pregnancy, where the risk is 5-20 per 10,000 YL (pregnancy data are based on the actual duration of pregnancy in standard studies; based on the assumption that pregnancy lasts 9 months, the risk is 7 to 27 cases per 10,000 YL).
In women in postpartum period the risk of developing VTE ranges from 40 to 65 cases per 10,000 LL. VTE leads to fatal outcome in 1-2% of cases.
According to research results, women using the drug NuvaRing are at greater risk of developing VTE, similar to that of women using COCs (adjusted risk ratio is presented in the table below).
In a large prospective observational study, TASC (Transatlantic Active Study of the Safety of the Drug NuvaRing for Cardiovascular Medicine) vascular system) the risk of developing VTE was assessed in women who started using the drug NuvaRing or COCs, switched to the drug NuvaRing or COCs from other contraceptives, or resumed using the drug NuvaRing or COCs in a population of typical users.

The women were observed for 24-48 months.
The results showed a similar level of risk of developing VTE in women using the drug NuvaRing (incidence of 8.3 cases per 10,000 YL) and in women using COCs (incidence of 9.2 cases per 10,000 YL).
For women using COCs, excluding desogestrel, gestodene and drospirenone, the incidence of VTE was 8.9 cases per 10,000 women.
A retrospective cohort study initiated by the FDA (US Food and Drug Administration) showed that the incidence of VTE in women who started using the drug NuvaRing was 11.4 cases per 10,000 YL, while in women who started use COCs containing levonorgestrel, the incidence of VTE is 9.2 cases per 10,000 vitreous.

There are extremely rare cases of thrombosis of other blood vessels(for example, arteries and veins of the liver, mesenteric vessels, kidneys, brain and retina) when using COCs. It is unknown whether these cases are related to the use of COCs.
Possible symptoms of venous or arterial thrombosis may include pain in one leg and/or swelling; sudden severe chest pain, possibly radiating to left hand; attack of shortness of breath, cough; any unusual, severe, prolonged headaches; sudden partial or total loss vision; double vision; slurred speech or aphasia; dizziness; collapse, with or without focal epileptic seizure; sudden weakness or severe numbness on one side of the body or any part of the body; movement disorders; "sharp" stomach.

Risk factors for the development of venous thrombosis and embolism:
- age;
- presence of diseases in the family history (venous thrombosis and embolism in brothers/sisters at any age or in parents at a relatively early age). If you suspect hereditary predisposition before starting the use of any hormonal contraceptives, a woman should be referred to a specialist for consultation;
- prolonged immobilization, major surgical interventions, any surgical interventions on the lower extremities or serious trauma. In such situations, it is recommended to stop using the drug (in case elective surgery no less than 4 weeks) with subsequent resumption of use no earlier than 2 weeks after full recovery motor activity;
- for obesity (body mass index more than 30 kg/m2);
- possibly thrombophlebitis of the superficial veins and varicose veins veins

There is no consensus on the possible role of these conditions in the etiology of venous thrombosis.
Risk factors for the development of complications of arterial thromboembolism:
- age;
- smoking (with heavy smoking and with age, the risk increases even more significantly, especially in women over 35 years of age);
- dislipoproteinemia;
- obesity (body mass index more than 30 kg/m2);
- hypertension;
- migraine;
- heart valve disease;
- atrial fibrillation;
- presence of diseases in the family history (arterial thrombosis in brothers/sisters at any age or in parents at a relatively early age). If a hereditary predisposition is suspected, the woman should be referred to a specialist for consultation before starting any hormonal contraceptives.

Biochemical factors that may indicate hereditary or acquired predisposition to venous or arterial thrombosis include activated protein C resistance, hyperhomocysteinemia, antithrombin III deficiency, protein C deficiency, protein S deficiency, antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant).
Other conditions that can lead to unwanted circulatory problems include diabetes mellitus, systemic lupus erythematosus, hemolytic uremic syndrome and chronic inflammatory bowel disease (such as Crohn's disease or ulcerative colitis), as well as sickle cell anemia.
It is necessary to take into account the increased risk of thromboembolism in the postpartum period.
An increase in the frequency or severity of migraines (which may be a prodromal symptom of cerebrovascular accidents) while using hormonal contraceptives may be a reason to immediately discontinue use of hormonal contraceptives.
Women using CHCs should be advised to consult a doctor if possible symptoms thrombosis If thrombosis is suspected or confirmed, CHC use should be discontinued. In this case, it is necessary to use effective contraception, since anticoagulants (coumarins) have a teratogenic effect.

Risk of developing tumors
The most important risk factor for developing cervical cancer is infection with the human papillomavirus (HPV).
Epidemiological studies have shown that long-term use COCs lead to an additional increase in this risk, but it remains unclear to what extent this is due to other factors such as more frequent studies of cervical smears and differences in sexual behavior, incl. use of barrier contraceptives. It remains unclear how this effect associated with the use of the drug NuvaRing.
A meta-analysis of 54 epidemiological studies found a small increase (1.24) in the relative risk of breast cancer in women taking combined hormonal oral contraceptives.
The risk gradually decreases over 10 years after stopping the drugs.

Breast cancer rarely develops in women under 40 years of age, so the additional incidence of breast cancer in women who take or have taken COCs is small compared to the overall risk of developing breast cancer.
Breast cancer diagnosed in women who use COCs is clinically less severe than cancer diagnosed in women who have never used COCs.
An increased risk of developing breast cancer may be
due to both the fact that women taking COCs are diagnosed with breast cancer earlier, and biological effects COC, or a combination of both of these factors.
In rare cases, cases of development of benign, and even more rarely, malignant liver tumors have been observed in women taking COCs. In some cases, these tumors led to the development of life-threatening bleeding in abdominal cavity. The doctor should consider the possibility of a liver tumor if differential diagnosis diseases in a woman taking NuvaRing, if the symptoms include sharp pain in the upper abdomen, enlarged liver or signs of intra-abdominal bleeding.

Other states
Women with hypertriglyceridemia or a corresponding family history have an increased risk of developing pancreatitis when taking hormonal contraceptives.
Many women taking hormonal contraceptives there is a slight increase in blood pressure, however clinically significant increase Blood pressure is rarely observed.
A direct connection between the use of hormonal contraceptives and the development of arterial hypertension has not been established.
If a constant increase in blood pressure is observed when using the drug NuvaRing, you should contact your doctor to decide whether to remove the vaginal ring and prescribe antihypertensive therapy. With adequate blood pressure control using antihypertensive drugs, it is possible to resume use of the drug NuvaRing.
During pregnancy and during the use of combined oral contraceptives, development or worsening of following states, although their relationship with the use of contraceptives has not been definitively established: jaundice and/or itching caused by cholestasis, formation of stones in gallbladder, porphyria, systemic lupus erythematosus, hemolytic-uremic syndrome, Sydenham's chorea (chorea minor), herpes of pregnancy, hearing loss due to otosclerosis, (hereditary) angioedema.

Acute or chronic liver dysfunction may serve as a basis for discontinuing the drug NuvaRing until liver function indicators normalize.
Recurrence of cholestatic jaundice, previously observed during pregnancy or during the use of sex steroids, requires discontinuation of the drug NuvaRing.
Although estrogens and progestogens may influence peripheral insulin resistance and tissue glucose tolerance, there is no evidence to support the need to change hypoglycemic therapy during the use of hormonal contraceptives. However, women with diabetes should be under constant medical supervision when using NuvaRing, especially in the first months of contraception.
There is evidence of a worsening of Crohn's disease and ulcerative colitis when using hormonal contraceptives.

In rare cases facial skin pigmentation may occur(chloasma), especially if it occurred earlier during pregnancy.
Women predisposed to the development of chloasma should avoid exposure to sunlight and ultraviolet radiation.
The following conditions may prevent the ring from being inserted correctly or may cause it to fall out: cervical prolapse, bladder and/or rectal hernia, severe chronic constipation.
In very rare cases, women have unintentionally inserted the NuvaRing vaginal ring into the urethra and possibly into the bladder. When symptoms of cystitis appear, it is necessary to consider the possibility of incorrect insertion of the ring.
Cases of vaginitis have been described during use of the drug NuvaRing. There is no evidence that the treatment of vaginitis affects the effectiveness of the use of the drug NuvaRing, as well as evidence that the use of the drug NuvaRing influences the effectiveness of the treatment of vaginitis.
Very rare cases of difficult ring removal have been described that required removal by a medical professional.

Medical examination/consultation
Before prescribing the drug NuvaRing or resuming its use, you should carefully review the woman’s medical history (including family history) and conduct gynecological examination to exclude pregnancy.
It is necessary to measure blood pressure, conduct an examination of the mammary glands, pelvic organs, including a cytological examination of cervical smears and some laboratory tests, to exclude contraindications and reduce the risk of possible side effects of the drug.
Frequency and character medical examinations depend on individual characteristics each patient, but medical examinations are carried out at least once every 6 months.
A woman should read the instructions and follow all recommendations. The woman should be informed that NuvaRing does not protect against HIV infection (AIDS) and other sexually transmitted diseases.
Reduced efficiency
The effectiveness of the drug NuvaRing may decrease if the regimen is not followed or concomitant therapy is carried out.

Reduced cycle control
While using the drug NuvaRing, acyclic bleeding (spotting or sudden bleeding) may occur. If such bleeding occurs after regular cycles against the background of correct use of the drug NuvaRing, you should contact your attending gynecologist to carry out the necessary diagnostic studies, incl. to exclude organic pathology or pregnancy. A diagnostic curettage may be required.
Some women do not bleed after the ring is removed. If the drug NuvaRing was used according to the instructions, it is unlikely that the woman is pregnant. If the recommendations of the instructions are not followed and there is no bleeding after removing the ring, as well as if there is no bleeding for two cycles in a row, pregnancy must be excluded.

Effects of ethinyl estradiol and etonogestrel on a sexual partner
The extent of exposure and possible pharmacological effects of ethinyl estradiol and etonogestrel on male sexual partners due to absorption through penile tissue have not been studied.
Laboratory research
The use of contraceptive steroids may affect the results of certain laboratory research, including biochemical indicators of liver, thyroid, adrenal and kidney function, plasma content of transport proteins (for example, corticosteroid binding globulin and sex hormone binding globulin), lipid/lipoprotein fractions, indicators carbohydrate metabolism and indicators of coagulation and fibrinolysis. Indicators, as a rule, vary within normal values.
Impact on the ability to drive vehicles and operate machinery
Based on information about the pharmacodynamic properties of the drug NuvaRing, it can be expected that it does not affect the ability to drive vehicles and work with machinery.
Considering the pharmacodynamic properties of the drug NuvaRing, its effect on the ability to drive a car and use complex equipment is not expected.

Interaction with
other medicinal
by other means:

Interaction between hormonal contraceptives and other drugs may lead to the development of acyclic bleeding and/or contraceptive failure.
The literature describes the following interactions with combined oral contraceptives in general.
There may be an interaction with drugs that induce microsomal enzymes, which can lead to increased clearance of sex hormones.
Interactions have been established with the following drugs phenytoin, barbiturates, primidone, carbamazepine, rifampicin, and possibly oxcarbazepine, topiramate, felbamate, ritonavir, griseofulvin and preparations containing St. John's wort.
When treating any of the listed drugs, you should temporarily use a barrier method of contraception (condom) in combination with the drug Nuvaring or choose another method of contraception.

During concomitant use of drugs that cause the induction of microsomal liver enzymes, and for 28 days after their discontinuation, barrier methods of contraception should be used.
If concomitant therapy is to be continued after 3 weeks of ring use, the next ring should be administered immediately without the usual interval.
Reduced effectiveness of oral contraceptives containing ethinyl estradiol has been observed with concomitant use of antibiotics such as ampicillin and tetracyclines.
The mechanism of this effect has not been studied. In a pharmacokinetic interaction study, oral administration of amoxicillin (875 mg 2 times a day) or doxycycline (200 mg/day, then 100 mg/day) for 10 days while using Nuvaring had little effect on the pharmacokinetics of etonogestrel and ethinyl estradiol.

When using antibiotics (excluding amoxicillin and doxycycline), you should use a barrier method of contraception (condom) during treatment and for 7 days after stopping antibiotics.
If concomitant therapy is to be continued after 3 weeks of ring use, the next ring should be administered immediately without the usual interval.
Pharmacokinetic studies have not revealed the effect of the simultaneous use of antifungals and spermicides on the contraceptive effectiveness and safety of Nuvaring.
When using suppositories in combination with antifungal drugs the risk of ring rupture increases slightly.

Hormonal contraceptives can cause disruption of the metabolism of other drugs.
Accordingly, their concentrations in plasma and tissues may increase (for example, cyclosporine) or decrease (for example, lamotrigine).
To exclude possible interactions, it is necessary to study the instructions for use of other drugs.
Pharmacokinetic data show that the use of tampons does not affect the absorption of hormones, released from the Nuvaring vaginal ring.
In rare cases, the ring may be accidentally removed when removing the tampon.

Pregnancy:

Drug NuvaRing intended to prevent pregnancy.
If a woman wants to stop using the drug in order to become pregnant, it is recommended to wait for the restoration of the natural cycle to conceive, as this will help to correctly calculate the date of conception and birth.
Pregnancy
The use of NuvaRing during pregnancy is contraindicated.
If pregnancy occurs, the ring should be removed.
Extensive epidemiological studies have not found an increased risk of developing birth defects in children born to women who took COCs before pregnancy, as well as teratogenic effects in cases where women took COCs in early pregnancy without knowing about it.
Although this applies to all COCs, it is not known whether this also applies to NuvaRing. A clinical study in a small group of women showed that, despite the fact that the drug NuvaRing is inserted into the vagina, the concentrations of contraceptive hormones inside the uterus when using the drug NuvaRing are similar to those when using COCs.
Pregnancy outcomes in women who used NuvaRing during a clinical trial have not been described.
Breastfeeding period
The use of NuvaRing during breastfeeding is not indicated.
The composition of the drug can affect lactation, reduce the amount and change the composition of breast milk.
Small quantities contraceptive steroids and/or their metabolites may be excreted in milk, but there is no evidence of their negative influence on children's health was not received.

Overdose:

Serious consequences of an overdose of hormonal contraceptives have not been described.
Symptoms: nausea, vomiting, slight vaginal bleeding in young girls.
Treatment: carry out symptomatic therapy. There are no antidotes.

Release form:

Vaginal ring Nuvaring smooth, transparent, colorless or almost colorless, without major visible damage, with a transparent or almost transparent area at the junction, in waterproof aluminum foil bags of 1 or 3 pcs.

Storage conditions:

The drug should be stored out of the reach of children at a temperature of 2° to 8°C.
Shelf life - 3 years.

1 Nuvaring ring contains:
- active substance: ethinyl estradiol - 2.7 mg, etonogestrel - 11.7 mg;
- excipients: ethylene and vinyl acetate copolymer (28% vinyl acetate) - 1677 mg, ethylene and vinyl acetate copolymer (9% vinyl acetate) - 197 mg, magnesium stearate - 1.7 mg.

The NuvaRing contraceptive is a soft and smooth ring that is inserted into the vagina for a period of 3 weeks. In internal cavity genital organs, it occupies the most comfortable position for a woman, adapting to the individual characteristics of the physique. Thanks to its flexibility, the ring does not cause the slightest discomfort and does not create obstacles to sports. Moreover, during sexual intercourse, neither partner feels the ring.

NuvaRing sizes are universal for women of any weight and build: its diameter is 54 mm and its thickness is 4 mm. The ring is produced in the Netherlands. Please note that there are no birth control pills of the same name.

How does NuvaRing work?

Under the antiallergic shell of this product contains minimum portions estrogen and progestogen. These are female sex hormones that have great value for her reproductive system. Inside the vagina, the ring acquires the temperature of a person’s body, and its shell becomes porous and releases hormones contained under it into the cavity of the uterus and ovaries. Action active substances targeted, hormonal effects on other organs in the body, except the genitals, do not apply. The concentration of these hormones is enough to negate the process of egg maturation and its release from the follicle. This means that pregnancy will not occur under such conditions.

Advantages of a hormonal ring

1. Undeniable reliability.
2. Simplicity and comfortable use (you only need to change the ring once a month).
3. A microscopic portion of hormones in the ring, which makes it absolutely safe.
4. Exclusively local action active substances.
5. The use of NuvaRing does not affect a woman’s weight.
6. Thanks to the ring, the monthly cycle becomes more regular, and the pain during menstruation is dulled.

Disadvantages of the hormonal ring

1. For some women, this method of birth control seems unusual from a psychological point of view.
2. Manufacturers of NuvaRing do not guarantee complete protection against sexually transmitted diseases.
3. The hormonal ring has quite a few contraindications.

How to use Nuvaring

The ring is inserted during menstruation on the first to fifth day (but not later!). Wash your hands thoroughly, then take the most comfortable position for you: lie down, squat, or lean your back against a wall and lift one leg.

Squeeze the pliable ring tightly with your fingers so that it decreases in diameter and insert deep into the vagina. If you feel the contraceptive device after insertion, adjust it with your fingers until this discomfort disappears. Don't worry about the ring being in the "wrong" place - if you don't feel it, it means it's positioned correctly in the vagina.

The NuvaRing should remain inside you for three weeks. If you accidentally remove the ring (this can happen when changing a sanitary tampon), rinse it in warm water and reinsert it. When the hormonal product expires, carefully remove it by prying it with your index finger or squeezing it with your middle and index fingers.

This is important!

MirSovetov hastens to draw your attention to the following rules for using the NuvaRing hormonal ring.

One ring is effective for one. You absolutely must remove it on the 22nd day after you installed it. In order not to get confused with the dates, you need to remember what day of the week you put the ring on - on the same day of the week you need to remove it. For example, if you put it on Thursday, you take it out 3 weeks later on Thursday. The safest thing, of course, is to immediately mark the start and end days of NuvaRing use on the calendar.

After the ring has been removed, rest for 7 days, and on the 8th day a new ring is inserted.

Attention! During the first week of using NuvaRing, doctors strongly recommend using a condom as an additional barrier method of protection against unwanted pregnancy.

How to use a hormonal ring after an abortion or childbirth

If you had it done in the first 3 months of pregnancy, place the ring in your vagina immediately after surgery. Please note that in this case it is not necessary to use a condom in the first 7 days after injection.

If some time has passed after the abortion, wait until your period and insert the hormonal ring on any day of your period no later than the fifth day. Use during the first week is mandatory.

If the abortion was performed in the second trimester, you can use NuvaRing only 3-4 weeks after the abortion. The same rule applies to childbirth. In this case, there is no need for barrier contraception in the form of a condom.

If 21 days have passed since the abortion or childbirth and during this time you have had sexual intercourse, wait until your first period to make sure that you are not pregnant. Insert the ring during your period and be sure to use a condom for 1 week.

Bleeding when using NuvaRing and after removing it

Be prepared for the fact that in many women, the abolition of the hormonal ring provokes the development of bleeding, which is explained by the cessation of the action of the active components of NuvaRing on reproductive system. You will most likely notice blood 2-3 days after removal contraceptive. Bleeding may stop immediately after the next ring is inserted or earlier.

Sometimes temporarily stopping NuvaRing does not cause bleeding. This phenomenon is considered normal if the contraceptive ring was used strictly following the rules for its use, and there was no bleeding only once. However, if a woman deviates from these recommendations and there is no blood 2 times in a row, pregnancy is suspected. A gynecologist will help clarify the situation.

During the period of wearing the ring, scanty and inconsistent bleeding may sometimes appear in the vagina. The unexpected appearance of intense bleeding also occurs. Spotting can be ignored (they usually stop quickly), but heavy bleeding- a good reason to immediately visit a antenatal clinic.

There will be no difficulties with canceling NuvaRing: just remove the ring when you decide not to use protection anymore. The body will be freed from the influence of estrogen and progestogen and will very quickly restore ovulation. Conception can occur in the first month after discontinuation of NuvaRing. No unpleasant consequences for pregnancy were noted after using the hormonal ring.

Side effects of NuvaRing

Side effects are uncommon with this contraceptive. Sometimes something may bother a woman at the beginning of using the ring, but all discomfort quickly disappears on its own. Here are some of them.

The vaginal ring is smooth, transparent, colorless or almost colorless, without major visible damage, with a transparent or almost transparent area at the junction.

Active ingredients: ethinyl estradiol 2.7 mg, etonogestrel 11.7 mg. Excipients: ethylene vinyl acetate copolymer (28% vinyl acetate), ethylene vinyl acetate copolymer (9% vinyl acetate), magnesium stearate.

Pharmacological action

Combined hormonal contraceptive drug for intravaginal use. Contains etonogestrel, which is a progestogen, a derivative of 19-nortestosterone, and ethinyl estradiol, which is an estrogen. The main mechanism of contraceptive action of the drug NuvaRing is inhibition of ovulation. The progestin component (etonogestrel) inhibits the synthesis of LH and FSH by the pituitary gland and, thus, prevents follicle maturation (blocks ovulation).

The Pearl index, an indicator reflecting the frequency of pregnancy in 100 women during a year of contraception, when using the drug NuvaRing is 0.96. The use of the drug reduces the pain and intensity of menstrual-like bleeding, reduces the frequency of acyclic bleeding and the likelihood of developing iron deficiency conditions. In addition, there is evidence of a reduced risk of endometrial and ovarian cancer with the use of the drug. NuvaRing does not reduce bone mineral density.

Indications for use

• intravaginal contraception.

Directions for use

NuvaRing is inserted into the vagina once every 4 weeks. The ring is in the vagina for 3 weeks and then removed on the same day of the week on which it was placed in the vagina; after a week's break, a new ring is inserted. For example: if the NuvaRing ring was installed on Wednesday at approximately 10:00 pm, then it should be removed on Wednesday 3 weeks later at approximately 10:00 pm; on the following Wednesday a new ring is inserted.

Bleeding associated with discontinuation of the drug usually begins 2-3 days after removal of the NuvaRing and may not completely stop until a new ring is installed.

Start using Nuvaring

• Hormonal contraceptives were not used in the previous menstrual cycle
  NuvaRing should be administered on the first day of the cycle (i.e., the first day of menstruation). It is possible to install a ring on days 2-5 of the cycle, however, in the first cycle in the first 7 days of using the drug NuvaRing, additional use of barrier methods of contraception is recommended.
• Switching from taking combined oral contraceptives
  NuvaRing should be administered on the last day of the free interval in taking combined hormonal contraceptives (pills or patch). If a woman has been taking combined hormonal contraceptives correctly and regularly and is confident that she is not pregnant, she can switch to using a vaginal ring on any day of her cycle. The duration of the interval in taking hormonal contraceptives should not exceed the recommended period.
• Switching from progestin-only contraception (mini-pill, implant, or injectable contraception) or progestogen-releasing intrauterine device (IUD)
  A woman taking the mini-pill can switch to using NuvaRing on any day (the ring is inserted on the day the implant or IUD is removed or on the day of the next injection). In all these cases, the woman should use a barrier method of contraception for the first 7 days after insertion of the ring.
• After an abortion performed in the first trimester of pregnancy
  You can start using NuvaRing immediately after an abortion. In this case there is no need for additional use other contraceptives. If the use of NuvaRing immediately after an abortion is undesirable, the ring should be used in the same way as if hormonal contraceptives were not used in the previous cycle. In the interval, the woman is recommended an alternative method of contraception.
• After childbirth or abortion performed in the second trimester of pregnancy
  The use of NuvaRing should begin within the 4th week after childbirth (if the woman is not breastfeeding) or abortion in the second trimester. If the use of NuvaRing is started at a later date, then additional use of barrier methods of contraception is necessary in the first 7 days of using NuvaRing. However, if sexual intercourse has already taken place during this period, you must first exclude pregnancy or wait until your first menstruation before starting to use the drug NuvaRing.

The contraceptive effect and cycle control may be impaired if the patient does not comply with the recommended regimen. To avoid loss of contraceptive effect in case of deviation from the regimen, you must follow the following recommendations.

Extending the break from using the ring

If you had sexual intercourse during a break from using the ring, pregnancy should be ruled out. How longer break, the higher the likelihood of pregnancy. If pregnancy is ruled out, a new ring should be inserted into the vagina as quickly as possible. Over the next 7 days, an additional barrier method of contraception, such as a condom, can be used.

If the ring has been temporarily removed from the vagina

If the ring remained outside the vagina less than 3 hours, the contraceptive effect will not decrease. The ring should be reinserted into the vagina as soon as possible.

If the ring was left outside the vagina for more than 3 hours during the first or second week of use, then the contraceptive effect may be reduced. You should place the ring in your vagina as soon as possible. Over the next 7 days, you must use a barrier method of contraception, such as a condom. The longer the ring was outside the vagina and the closer this period is to the 7-day break in using the ring, the higher the likelihood of pregnancy.

If the ring was outside the vagina for more than 3 hours during the third week of use, then the contraceptive effect may be reduced. The woman should throw away this ring and choose one of two methods:

1. Immediately install a new ring. Please note that the new ring can be used for the next 3 weeks. In this case, there may be no bleeding associated with the cessation of the drug's effect. However, spotting or bleeding in the middle of the cycle is possible.
2. Wait for bleeding associated with the cessation of the drug, and insert a new ring no later than 7 days after removing the previous ring. This option should only be chosen if the ring use regimen has not been violated previously during the first 2 weeks.

Extended use of the ring

If the drug NuvaRing was used no more maximum term at 4 weeks, then the contraceptive effect remains sufficient. You can take a week's break from using the ring and then insert a new ring. If NuvaRing remained in the vagina more than 4 weeks, then the contraceptive effect may worsen, so pregnancy must be ruled out before inserting a new ring.

To change the time of onset of menstrual bleeding

To postpone (prevent) menstrual-like withdrawal bleeding, you can insert a new ring without a week's break. The next ring must be used within 3 weeks. This may cause bleeding or spotting. Then, after the usual one-week break, you should return to regular use of NuvaRing.

To postpone the onset of bleeding on another day of the week, it can be recommended to take a shorter break from using the ring (for as many days as necessary). The shorter the interval between ring use, the higher the likelihood that there will be no bleeding after ring removal and no bleeding or spotting will occur when the next ring is used.

Ring damage

In rare cases, ring rupture has occurred when using NuvaRing. The core of the NuvaRing ring is solid, so its contents remain intact, and the release of hormones does not change significantly. If the ring ruptures, it usually falls out of the vagina. If the ring ruptures, a new ring must be inserted.

Ring falling out

NuvaRing has sometimes been reported to fall out of the vagina, for example, when it was inserted incorrectly, when a tampon was removed, during sexual intercourse, or due to severe or chronic constipation. In this regard, it is advisable for a woman to regularly check the presence of the NuvaRing ring in the vagina.

Incorrect insertion of the ring

In very rare cases, women have inadvertently inserted NuvaRing into the urethra. When symptoms of cystitis appear, it is necessary to consider the possibility of incorrect insertion of the ring.

Rules for using NuvaRing

The patient can independently insert NuvaRing into the vagina. To insert the ring, a woman should choose the position that is most comfortable for her, for example, standing, raising one leg, squatting, or lying down. NuvaRing must be squeezed and inserted into the vagina until the ring is in a comfortable position. The exact position of NuvaRing in the vagina is not decisive for the contraceptive effect.

After insertion, the ring must remain in the vagina continuously for 3 weeks. If the ring was accidentally removed, it should be washed with warm (not hot) water and immediately inserted into the vagina.

To remove the ring, you can pick it up with your index finger or squeeze it between your index and middle fingers and pull it out of the vagina.

Side effect

The following side effects may occur when using Nuvaring:

System-organ class	Side effects
Infections and infestations	Vaginal infection (candidiasis, vaginitis). Cystitis, cervicitis, urinary tract infections
Metabolic disorders	Increase in body weight. Increased appetite
Mental disorders	Depression, decreased libido, mood changes
Nervous system	Headache, migraine. Dizziness
Organ of vision	Visual impairment
Cardiovascular system	"Tides"
Digestive system	Abdominal pain, nausea. Bloating, diarrhea, vomiting, constipation
Skin	Acne. Alopecia, eczema, itchy skin. Skin rash
Musculoskeletal system	Pain in the lumbar region, muscle spasms, pain in the limbs
Urinary system	Dysuria, urgency, pollakiuria
Reproductive system	Engorgement and tenderness of the mammary glands, genital itching in women, pelvic pain, vaginal discharge. Amenorrhea, cervical polyps, contact (during sexual intercourse) spotting (bleeding), dyspareunia, ectropion of the uterus, fibrocystic mastopathy, menorrhagia, metrorrhagia, PMS, dysmenorrhea, uterine spasm, burning sensation in the vagina, dryness of the vulva and vaginal mucosa . Local reactions on the part of the penis (feeling foreign body partner during sexual intercourse, irritation of the penis during hypersensitivity to the components of the drug)
Others	Prolapse of the vaginal ring. Ring rupture (damage). Fatigue, malaise, abdominal pain, swelling, sensation of a foreign body in the vagina

Contraindications for use

• venous thrombosis (including a history), including deep vein thrombosis, pulmonary embolism;
• arterial thrombosis (including a history), including stroke, transient cerebrovascular accidents, myocardial infarction and/or precursors of thrombosis, including angina pectoris, transient ischemic attack;
• heart defects with thrombogenic complications;
• changes in blood parameters indicating a predisposition to the development of venous or arterial thrombosis, including resistance to activated protein C, antithrombin III deficiency, protein C deficiency, protein S deficiency, hyperhomocysteinemia and antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant);
• migraine with focal neurological symptoms;
• arterial hypertension (systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg);
• diabetes mellitus with vascular damage;
• pancreatitis incl. history, in combination with severe hypertriglyceridemia;
• severe liver diseases, until normalization of liver function indicators;
• liver tumors (including history);
• hormone-dependent malignant tumors (for example, breast cancer), known, suspected or in history;
• bleeding from the vagina of unknown etiology;
• pregnancy (including suspected);
• lactation period;
• surgical interventions followed by long-term immobilization;
• smoking (15 or more cigarettes per day) in women 35 years of age and older;
• hypersensitivity to the components of the drug.

With caution the drug should be prescribed if any of the following disease conditions or risk factors are present; in such cases, the doctor must carefully weigh the benefit-risk ratio of using the drug NuvaRing:

• venous or arterial thrombosis (in siblings and/or parents);
• obesity (body mass index more than 30 kg/m2);
• dyslipoproteinemia;
• varicose veins (in combination with thrombophlebitis of the superficial veins);
• atrial fibrillation;
• diabetes mellitus;
• systemic lupus erythematosus;
• hemolytic-uremic syndrome;
• epilepsy;
• chronic inflammatory bowel diseases (Crohn's disease and ulcerative colitis);
• sickle cell anemia;
• congenital hyperbilirubinemia (Gilbert, Dubin-Johnson, Rotor syndromes);
• chloasma;
• uterine fibroids;
• fibrocystic mastopathy;
• conditions that make it difficult to use a vaginal ring: cervical prolapse, bladder hernia, rectal hernia, severe chronic constipation;
• adhesions in the vagina;
• smoking (less than 15 cigarettes per day) in women 35 years of age and older.

If the disease worsens, the condition worsens, or other risk factors appear, the woman should also consult a doctor and possibly discontinue the drug.

Although a cause-and-effect relationship has not been convincingly proven, caution should be exercised when prescribing NovaRing if the following conditions/diseases have previously developed or worsened during the use of any other hormonal contraceptives or previous pregnancy: jaundice and/or itching associated with cholestasis, formation of gallstones, porphyria, Sydenham's chorea, herpes of pregnancy, otosclerosis with hearing loss, (hereditary) angioedema.

Recurrence of cholestatic jaundice and/or cholestasis with itching, which was observed during pregnancy or previous use of sex hormones, is grounds for discontinuing the use of NuvaRing.

Use of NuvaRing during pregnancy and breastfeeding

The use of NuvaRing is contraindicated during pregnancy, suspected pregnancy and lactation. NuvaRing is contraindicated during breastfeeding. NuvaRing can affect lactation, reduce the amount and change the composition of breast milk. Small amounts of contraceptive steroids and/or their metabolites may be excreted in milk.

Use for liver dysfunction

NuvaRing is contraindicated in serious illnesses liver (until normalization of function indicators).

Special instructions

Before prescribing or resuming the use of the drug NuvaRing, you should conduct a medical examination: analyze your medical history (including family history) and exclude pregnancy; measure blood pressure; conduct an examination of the mammary glands, pelvic organs, including cytological examination of smears from the cervix; conduct some laboratory tests to exclude contraindications and reduce the risk of possible side effects of the drug NuvaRing. The frequency and nature of medical examinations are carried out by a specialist, taking into account the individual characteristics of each woman, but at least once every 6 months.

The patient should read the instructions for use of the drug NuvaRing and follow all recommendations.

It should be kept in mind that NuvaRing does not protect against HIV infection (AIDS) and other sexually transmitted diseases.

Women aged 40 years and older, women with cervical intraepithelial neoplasia, as well as women who smoke at any age require additional consultation with a gynecologist before prescribing NuvaRing.

The effectiveness of the drug NuvaRing may decrease if the regimen is not followed.

While using NuvaRing, acyclic bleeding (spotting or sudden bleeding) may occur. If such bleeding is observed after regular cycles while using NuvaRing in accordance with the instructions, you should contact your gynecologist to conduct the necessary diagnostic tests, incl. to exclude malignant tumor and pregnancy. A diagnostic curettage may be required.

Some women do not bleed after the ring is removed. If NuvaRing is used as directed, it is unlikely that the woman is pregnant. If the recommendations of the instructions are not followed and there is no bleeding after removing the ring, as well as if there is no bleeding in two cycles in a row, pregnancy must be excluded.

The most important risk factor for developing cervical cancer is infection with the human papillomavirus (HPV). Epidemiological studies have shown that long-term use of combined hormonal contraceptives further increases this risk, but the extent to which this is due to other factors remains unclear. The positive role of regular examinations of women by a gynecologist and the use of barrier methods of contraception are obvious. There is no information about an increased risk of developing cervical cancer in HPV-infected women using NuvaRing.

Studies have found a small increase in the relative risk (1.24) of developing breast cancer in women taking combined hormonal oral contraceptives, but this risk gradually decreases over 10 years after discontinuation of the drugs. Breast cancer is rare in women under 40 years of age, so the additional incidence of breast cancer in women who have received or continue to use combined oral contraceptives is small compared to the overall risk of developing breast cancer. There is evidence that women who took oral combined contraceptives have less breast cancer than women who have never used such medications. The possibility of the effect of the drug NuvaRing on the incidence of breast cancer is being studied.

In rare cases, women taking combined oral contraceptives have experienced benign tumors liver and even less often - malignant. In some cases, these tumors led to the development of life-threatening bleeding into the abdominal cavity. If severe pain appears in the upper abdomen, liver enlargement, or signs of intra-abdominal bleeding in a woman using NuvaRing, a liver tumor should be excluded.

Although many women taking hormonal contraceptives experience a slight increase in blood pressure, clinically significant hypertension is rare. A direct connection between the use of hormonal contraceptives and the development of arterial hypertension has not been established. However, if, when using the drug NuvaRing, there is a constant increase in blood pressure, the patient should contact her gynecologist; in such cases, the ring should be removed, antihypertensive therapy should be prescribed and the issue of choosing the most appropriate method of contraception should be decided, incl. possible resumption of use of the drug NuvaRing.

Although estrogens and progestogens can influence peripheral insulin resistance and tissue tolerance to glucose, there is no evidence to support the need to change hypoglycemic therapy during the use of hormonal contraceptives. However, women with diabetes should be under constant medical supervision when using NuvaRing, especially in the first months of contraception.

The use of contraceptive steroids may affect the results of certain laboratory tests, including biochemical parameters of liver, thyroid, adrenal and kidney function, plasma levels of transport proteins (for example, corticosteroid binding globulin and sex hormone binding globulin), lipid/lipoprotein fractions, carbohydrate metabolism parameters and indicators of coagulation and fibrinolysis. Indicators, as a rule, vary within normal values.

Serious surgery(including on the lower extremities) is a contraindication to the use of the drug. In case of planned surgery, it is recommended to stop using the drug at least 4 weeks in advance, and resume no earlier than 2 weeks after complete restoration of motor activity.

Women predisposed to the development of chloasma should avoid exposure to sunlight and ultraviolet radiation while using NuvaRing.

The extent of exposure and possible pharmacological effects of ethinyl estradiol and etonogestrel on the glans mucosa and skin of the penis have not been studied.

Impact on the ability to drive vehicles and operate machinery

Considering the pharmacodynamic properties of the drug NuvaRing, its effect on the ability to drive a car and use complex equipment is not expected.

Overdose

Serious consequences of an overdose of hormonal contraceptives have not been described. Suggested symptoms: nausea, vomiting, slight vaginal bleeding in young girls.

Treatment: carry out symptomatic therapy. There are no antidotes.

Drug interactions

Interactions between hormonal contraceptives and other drugs may lead to the development of acyclic bleeding and/or contraceptive failure. There may be an interaction with drugs that induce microsomal enzymes, which can lead to increased clearance of sex hormones.

The effectiveness of the drug NovaRing may be reduced with the simultaneous use of antiepileptic drugs (phenytoin, phenobarbital, primidone, carbamazepine, oxcarbazepine, topiramate, felbamate), anti-tuberculosis drugs (rifampicin), antimicrobial drugs (ampicillin, tetracycline, griseofulvin), possibly antiviral drugs(ritonavir) and medicines containing St. John's wort.

When treating any of the listed drugs, a woman should temporarily use a barrier method of contraception in combination with the drug NuvaRing or choose another method of contraception. When treated with drugs causing induction liver enzymes, the barrier method (condom) should be used during treatment and for 28 days after discontinuation of such drugs.

If concomitant therapy is to be continued after 3 weeks of ring use, the next ring should be administered immediately without the usual interval.

During treatment with antibiotics (excluding amoxicillin and doxycycline), it is necessary to use a barrier method of contraception (condom) during treatment and for 7 days after their discontinuation. If concomitant therapy is to be continued after 3 weeks of ring use, the next ring should be administered immediately without the usual interval.

As a result of studies of the pharmacokinetics of the effect on the contraceptive effectiveness and safety of the drug NovaRing when used simultaneously with antifungal agents and spermicides were not detected. When combined with suppositories and antifungal agents, the risk of ring rupture increases slightly.

Hormonal contraceptives can cause disruption of the metabolism of other drugs. Accordingly, their concentrations in plasma and tissues may increase (for example, cyclosporine) or decrease (for example, lamotrigine).

To exclude possible interactions, it is necessary to study the instructions for use of other drugs.

The use of tampons does not affect the effectiveness of NuvaRing. In rare cases, the ring may be accidentally removed when removing the tampon.