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NUVARING 0.12 MG/0.015 MG PER 24 HOURS VAGINAL DELIVERY SYSTEM

Active substance(s): ETHINYLESTRADIOL / ETONOGESTREL

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Transcript
You have forgotten to remove the ring
• If your ring has been left in place for between 3 and 4 weeks, it will still
protect you from pregnancy. Have your regular ring-free interval of one
week and subsequently insert a new ring.
• If your ring has been left in place for more than 4 weeks there is a
possibility of becoming pregnant. Contact your doctor before you start
with a new ring.
You have missed a menstrual period
• You have followed the instructions for NuvaRing
If you have missed a menstrual period but you followed the instructions
for NuvaRing, and have not used other medicines, it is very unlikely that
you are pregnant. Continue to use NuvaRing as usual. If you miss your
menstrual period twice in a row, however, you may be pregnant. Tell your
doctor immediately. Do not start the next NuvaRing until your doctor has
checked you are not pregnant.

• If you have not followed the instructions for NuvaRing
If you have missed a menstrual period and you did not follow the
instructions, and you do not have your expected period in the first normal
ring-free interval, you may be pregnant. Contact your doctor before you
start with a new NuvaRing.
You have unexpected bleeding
While using NuvaRing, some women have unexpected vaginal bleeding
between menstrual periods. You may need to use sanitary protection. In any
case, leave the ring in the vagina and continue to use the ring as normal. If
the irregular bleeding continues, becomes heavy or starts again, tell your
doctor.
You want to change the first day of your menstrual period.
If you follow the instructions for NuvaRing, your menstrual period (withdrawal
bleed) will begin in the ring-free interval. If you want to change the day it
starts, you can make the ring-free interval shorter (but never longer!).
For example, if your period usually begins on a Friday, you can change
this to a Tuesday (3 days earlier) from next month onwards. Simply
insert your next ring 3 days earlier than usual.
If you make your ring-free interval very short (for example, 3 days or less),
you may not have your usual bleeding. You may have spotting (drops or
flecks of blood) or breakthrough bleeding while using the next ring.

Rare: may affect up to 1 in 1,000 women
• harmful blood clots in a vein or artery, for example:
• in a leg or foot (i.e. DVT)
• in a lung (i.e. PE)
• heart attack
• stroke
• mini-stroke or temporary stroke-like symptoms, known as a transient
ischaemic attack (TIA)
• blood clots in the liver, stomach/intestine, kidneys or eye.
The chance of having a blood clot may be higher if you have any other
conditions that increase this risk. (See section 2 for more information
on the conditions that increase risk for blood clots and the symptoms
of a blood clot.)
• breast discharge
Not known (cannot be estimated from the available data)
• chloasma (yellowish-brown pigmentation patches on the skin, particularly of
the face)
• penis discomfort of the partner (such as irritation, rash, itching)

Reporting of side effects
If you get any side effects, talk to your doctor or pharmacist. This includes
any possible side effects not listed in this leaflet.
You can also report side effects directly via the Yellow Card Scheme at:
www.mhra.gov.uk/yellowcard
By reporting side effects you can help provide more information on the
safety of this medicine.

5







You can leave the new ring inserted for up to a maximum of 3 weeks.
You may experience spotting (drops or flecks of blood) or breakthrough
bleeding while using this new ring. When you want your period to begin,
just remove the ring. Have your regular ring free interval of one week and
subsequently insert a new ring.

NuvaRing 0.12 mg/0.015 mg per 24 hours, vaginal delivery system
(salmeterol xinafoate / fluticasone propionate)

Patient Information Leaflet
Important things to know about combined hormonal contraceptives
(CHCs):
• They are one of the most reliable reversible methods of contraception if
used correctly.
• They slightly increase the risk of having a blood clot in the veins and
arteries, especially in the first year or when restarting a combined
hormonal contraceptive following a break of 4 or more weeks.
• Please be alert and see your doctor if you think you may have symptoms
of a blood clot (see section 2 “Blood clots”).
Your medicine is called NuvaRing 0.12 mg/0.015 mg per 24 hours, vaginal
delivery system and will be referred to as NuvaRing throughout the rest of
this leaflet.

Breast cancer and liver tumours have been reported in users of combined
hormonal contraceptives. For more information, see section 2.2 Warnings
and precautions, Cancer.

If you are not sure how to proceed, contact your doctor for advice.
You want to delay your menstrual period
Although it is not the recommended regimen, delay of your menstrual
period (withdrawal bleed) is possible by inserting a new ring immediately
after removing the current ring, with no ring-free interval between rings.

Ref: 1622/140416/1/F

®




Read all of this leaflet carefully before you start using NuvaRing
because it contains important information for you.
• Keep this leaflet. You may need to read it again.
• If you have any further questions, ask your doctor or pharmacist.
• This medicine has been prescribed for you only. Do not pass it on to
others. It may harm them.
• If you get any side effects, talk to your doctor or pharmacist.
This includes any possible side effects not listed in this leaflet. See
section 4.
What is in this leaflet:
1 What NuvaRing is and what is it used for

How to store NuvaRing

2 What you need to know before you use NuvaRing
2.1 When you should not use NuvaRing
2.2 Warnings and precautions
Blood clots
Cancer
2.3 Children and adolescents
2.4 Other medicines and NuvaRing
Laboratory tests
2.5 Pregnancy and breast-feeding
2.6 Driving and using machines
3 How to use NuvaRing?
3.1 How to insert and remove NuvaRing
3.2 Three weeks in, one week out
3.3 When to start with the first ring
3.4 What to do if…
Your ring is accidentally expelled from the vagina
Your ring has temporarily been out of the vagina
Your ring breaks
You have inserted more than one ring
You have forgotten to insert a new ring after the ring-free interval
You have forgotten to remove the ring
You have missed a menstrual period
You have unexpected bleeding
You want to change the first day of your menstrual period
You want to delay your menstrual period
3.5 When you want to stop using NuvaRing
4 Possible side effects
5 How to store NuvaRing

Keep out of the sight and reach of children.
If you discover that a child has been exposed to the hormones from
NuvaRing, ask your doctor for advice.
Prior to dispensing to the patient, store at 2 – 8°C.
After dispensing to the patient, NuvaRing can be stored for up to 4
months at temperatures below 30°C. Store in the original package in
order to protect from light and moisture.
Do not use a NuvaRing if it was dispensed to you more than 4 months
ago. The dispensing date is stated on the carton and sachet.
Do not use NuvaRing after the expiry date which is stated on the carton
and sachet. The expiry date refers to the last day of that month.
Do not use NuvaRing if you notice a colour change in the ring or any
visible signs of deterioration.

Dispose of the used ring with the normal household waste, preferably inside
the reclosable sachet. Do not flush NuvaRing down the toilet. As with other
medicines, do not throw away any unused or outdated rings via wastewater
or household waste. Ask your pharmacist how to throw away any unused
rings no longer required. These measures will help protect the enviroment

You can ask your doctor for advice before deciding to delay your menstrual
period.
6
3.5 When you want to stop using NuvaRing
You can stop using NuvaRing any time you want.
If you do not want to become pregnant, ask your doctor about other
methods of birth control.
If you stop using NuvaRing because you want to get pregnant, you should
wait until you have had a natural period before trying to conceive. This helps
you calculate when the baby will be due.

4

Possible side effects

Like all medicines, NuvaRing can cause side effects, although not
everybody gets them. If you get any side effect, particularly if severe or
persistent, or have any change to your health that you think may be due to
NuvaRing, please talk to your doctor.
An increased risk of blood clots in your veins (venous thromboembolism
(VTE)) or blood clots in your arteries (arterial thromboembolism (ATE)) is
present for all women taking combined hormonal contraceptives. For more
detailed information on the different risks from taking combined hormonal
contraceptives, please see section 2, “What you need to know before you
use NuvaRing”.
If you are allergic to one of the ingredients of Nuvaring (hypersensitivity) you
may experience the following symptoms (frequency unknown): angioedema
[swollen face, tongue and/or throat and/or difficulty swallowing] or hives
together with difficulty breathing. If this happens, remove NuvaRing and
contact your doctor immediately.
Users of NuvaRing have reported the following side effects.
Common: may affect up to 1 in 10 women
• abdominal pain, feeling sick (nausea)
• yeast infection of the vagina (such as ‘thrush’); discomfort in the vagina
due to the ring; genital itching; secretion from the vagina
• headache or migraine; depressive moods; lower sex drive
• breast pain; pelvic pain; painful menstrual periods
• acne
• weight gain
• the ring falling out
Uncommon: may affect up to 1 in 100 women
• disturbed vision; dizziness
• swollen abdomen; vomiting, diarrhoea or constipation
• feeling tired, unwell or irritable; mood changes; mood swings
• extra fluid in the body (oedema)
• bladder or urinary tract infection
• difficulty or pain when passing urine; strong desire or need to pass
urine; passing urine more often
• problems during intercourse, including pain, bleeding or partner feeling
the ring
• increased blood pressure
• increased appetite
• back pain; muscle spasms; pain in legs or arms
• less sensitive skin
• sore or larger breasts; fibrocystic breast disease (cysts in the breasts
which may become swollen or painful)
• inflammation of the cervix; cervical polyps (growths in the cervix);
rolling outward of the margin of the cervix (ectropion)
• changes to menstrual periods (e.g. periods can be heavy, long,
irregular or stop altogether); pelvic discomfort; premenstrual syndrome;
spasm of the uterus
• vaginal infection (fungal and bacterial); burning feeling, smell, pain,
discomfort or dryness in the vagina or vulva
• hair loss, eczema, itching, rash or hot flushes.
• ring breakage

Page 4

Contents of the pack and other Information

What NuvaRing contains
• The active substances are: etonogestrel (11.7 mg) and
ethinylestradiol (2.7 mg)
• The other ingredients are: ethylene - vinyl acetate copolymer 28%,
vinyl acetate copolymer 9% (a type of plastic that will not dissolve in
the body) and magnesium stearate.

6

Contents of the pack and other Information
What NuvaRing contains
What NuvaRing looks like and contents of the pack
Marketing Authorisation Holder and Manufacturer

1

What NuvaRing is and what it is used for

Etonogestrel and ethinylestradiol are released from the ring at a rate of
0.120 mg/day and 0.015 mg/day, each for 3 weeks.
What NuvaRing looks like and contents of the pack
NuvaRing is a flexible, transparent, colourless to almost colourless ring, 54
mm wide.
Each ring is packed in a reclosable foil sachet. The sachet is packed in a
cardboard box together with this package leaflet. Each box contains 1 ring.
Manufacturer and Licence Holder
This medicine is manufactured by NV Organon, Kloosterstraat 6, 5349 AB
Oss The Netherlands and is procured from within the EU and repackaged by
the Product Licence Holder: Lexon (UK) Limited, Unit 18, Oxleasow Road,
East Moons Moat, Redditch, Worcestershire, B98 0RE.

NuvaRing is a contraceptive vaginal ring used to prevent pregnancy. Each
ring contains a small amount of two female sex hormones – etonogestrel and
ethinylestradiol. The ring slowly releases these hormones into the blood
circulation. Because of the low amount of hormones that is released,
NuvaRing is considered a low-dose hormonal contraceptive.
Since NuvaRing releases two different types of hormones it is a so-called
combined hormonal contraceptive.
4 mm

If you have any questions or are not sure about anything, ask your doctor or
pharmacist. They will have additional information about this medicine and will
be able to advise you.

POM PL Number: 5184/1622

54 mm

NuvaRing 0.12mg/0.015 mg per 24 hours,
vaginal delivery system

NuvaRing is a registered trademark of Merck Sharp & Dohme B.V.
Leaflet revision date: 14/04/16

NuvaRing works just like a combined contraceptive pill (the Pill) but instead
of taking a pill every day, the ring is used for 3 weeks in a row. NuvaRing
releases two female sex hormones that prevent the release of an egg cell
from the ovaries. If no egg cell is released you cannot become pregnant.

Blind or partially sighted?
Is this leaflet hard to see or read?
Phone Lexon (UK) Limited,
Tel: 01527 505414 for help.

2

What you need to know before you use NuvaRing

General notes
Before you start using NuvaRing you should read the information on blood
clots in section 2. It is particularly important to read the symptoms of a
blood clot – see section 2 “Blood clots”.
In this leaflet, several situations are described where you should stop
using NuvaRing, or where NuvaRing may be less reliable. In such
situations you should not have intercourse or you should take extra
non-hormonal contraceptive precautions – such as using a condom or
another barrier method. Do not use rhythm or temperature methods.
These methods can be unreliable because NuvaRing alters the monthly
changes of the body temperature and of the cervical mucus.













if you have ever had a heart attack, or a stroke;
if you have (or have ever had) angina pectoris (a condition that causes
severe chest pain and may be a first sign of a heart attack) or transient
ischaemic attack (TIA – temporary stroke symptoms);
if you have any of the following diseases that may increase your risk of a
clot in the arteries:
- severe diabetes with blood vessel damage
- very high blood pressure
- a very high level of fat in the blood (cholesterol or
triglycerides)
- a condition known as hyperhomocysteinaemia
if you have (or have ever had) a type of migraine called ‘migraine with
aura’;
if you have (had) inflammation of the pancreas (pancreatitis) associated
with high levels of fat in your blood.
if you have (had) severe liver disease and your liver is not yet working
normally.
if you have (had) a benign or malignant tumour in the liver.
if you have (had), or if you may have, cancer of the breast or the genital
organs.
if you have any unexplained vaginal bleeding.
if you are allergic to ethinylestradiol or etonogestrel, or any of the other
ingredients of this medicine (listed in section 6).

If any of these conditions appear for the first time while using NuvaRing,
remove the ring immediately and contact your doctor. In the meantime, use
non-hormonal contraceptive measures.
2.2 Warnings and precautions
When should you contact your doctor?
Seek urgent medical attention
- if you notice possible signs of a blood clot that may mean you are
suffering from a blood clot in the leg (i.e. deep vein thrombosis), a
blood clot in the lung (i.e. pulmonary embolism), a heart attack or a
stroke (see ‘Blood clots’ section below).
For a description of the symptoms of these serious side effects please go
to “How to recognise a blood clot”.
Tell your doctor if any of the following conditions apply to you.
If the condition develops, or gets worse while you are using NuvaRing,
you should also tell your doctor.
• if a close relative has or has ever had breast cancer;
• if you have epilepsy (see section 2.4:‘Other Medicines and NuvaRing’);
• if you have liver disease (for instance jaundice) or gallbladder disease
(for instance gallstones);
• if you have Crohn’s disease or ulcerative colitis (chronic inflammatory
bowel disease);
• if you have systemic lupus erythematosus (SLE - a disease affecting
your natural defense system);
• if you have haemolytic uraemic syndrome (HUS - a disorder of blood
clotting causing failure of the kidneys);
• if you have sickle cell anaemia (an inherited disease of the red blood
cells);
• if you have elevated levels of fat in the blood (hypertriglyceridaemia)
or a positive family history for this condition. Hypertriglyceridaemia has
been associated with an increased risk of developing pancreatitis
(inflammation of the pancreas);
• if you need an operation, or you are off your feet for a long time
(see in section 2 ‘Blood clots’);
• if you have just given birth you are at an increased risk of blood clots. You
should ask your doctor how soon after delivery you can start using
NuvaRing;
• if you have an inflammation in the veins under the skin (superficial
thrombophlebitis);
• if you have varicose veins;
• if you have a condition that occurred for the first time or worsened
during pregnancy or previous use of sex hormones (e.g. hearing loss,
porphyria [a disease of the blood], herpes gestationis [skin rash with
vesicles during pregnancy], Sydenham’s chorea [a disease of the nerves in
which sudden movements of the body occur], hereditary angioedema [you
should see your doctor immediately if you experience symptoms of
angioedema such as swollen face, tongue and/or throat and/or difficulty
swallowing or hives together with difficulty breathing];
• if you have (or have ever had) chloasma (yellowish-brown pigment
patches, so called ‘pregnancy patches’, particularly on the face). If so,
avoid too much exposure to the sun or ultraviolet light;
• if you have a medical condition that makes it difficult to use NuvaRing – for
example, if you are constipated, have a prolapse of the uterine cervix or
have pain during intercourse.
BLOOD CLOTS
Using a combined hormonal contraceptive such as NuvaRing increases your
risk of developing a blood clot compared with not using one. In rare cases a
blood clot can block blood vessels and cause serious problems.
Blood clots can develop
• in veins (referred to as a ‘venous thrombosis’, ‘venous thromboembolism’
or VTE)
• in the arteries (referred to as an ‘arterial thrombosis’, ‘arterial
thromboembolism’ or ATE).
Recovery from blood clots is not always complete. Rarely, there may be
serious lasting effects or, very rarely, they may be fatal.
It is important to remember that the overall risk of a harmful blood
clot due to NuvaRing is small.

NuvaRing, like other hormonal contraceptives, does not protect
against HIV infection (AIDS) or any other sexually transmitted disease.
2.1 When you should not use NuvaRing
You should not use NuvaRing if you have any of the conditions listed below.
If you do have any of the conditions listed below, you must tell your doctor.
Your doctor will discuss with you what other form of birth control would be
more appropriate.





if you have (or have ever had) a blood clot in a blood vessel of your legs
(deep vein thrombosis, DVT), your lungs (pulmonary embolus, PE) or other
organs;
if you know you have a disorder affecting your blood clotting - for instance,
protein C deficiency, protein S deficiency, antithrombin – III deficiency,
Factor V Leiden or antiphospholipid antibodies;
if you need an operation or if you are off your feet for a long time
(see section ‘Blood clots’);

Page 1

HOW TO RECOGNISE A BLOOD CLOT
Seek urgent medical attention if you notice any of the following signs
or symptoms.
Are you experiencing any of these
signs?

What are you possibly suffering
from?



Deep vein thrombosis

swelling of one leg or along a
vein in the leg or foot
especially when accompanied
by:
• pain or tenderness in the leg
which may be felt only when
standing or walking
• increased warmth in the
affected leg
• change in colour of the skin
on the leg e.g. turning pale,
red or blue

• sudden unexplained breathless






Pulmonary embolism

ness or rapid breathing;
sudden cough without an obvious
cause, which may bring up blood;
sharp chest pain which may
increase with deep breathing;
severe light headedness or
dizziness;
rapid or irregular heartbeat;
severe pain in your stomach;

Heart attack












discolouration of an extremity;
severe pain in your stomach
(acute abdomen).

You should be careful when removing a tampon to be sure that the ring
is not accidentally pulled out. If the ring does come out, simply rinse the ring
in cool to lukewarm water and immediately reinsert it.

Factors that increase your risk of a blood clot in a vein
The risk of a blood clot with NuvaRing is small but some conditions will
increase the risk. Your risk is higher:
• if you are very overweight (body mass index or BMI over 30 kg/m2);
• if one of your immediate family has had a blood clot in the leg, lung
or other organ at a young age (e.g. below the age of about 50). In this
case you could have a hereditary blood clotting disorder;
• if you need to have an operation, or if you are off your feet for a long time
because of an injury or illness, or you have your leg in a cast. The use of
NuvaRing may need to be stopped several weeks before surgery or while
you are less mobile. If you need to stop using NuvaRing ask your doctor
when you can start using it again.
• as you get older (particularly above about 35 years);
• if you gave birth less than a few weeks ago.

It is important to tell your doctor if any of these conditions apply to you, even
if you are unsure. Your doctor may decide that NuvaRing needs to be
stopped.

BLOOD CLOTS IN AN ARTERY

Factors that increase your risk of a blood clot in an artery
It is important to note that the risk of a heart attack or stroke from using
NuvaRing is very small but can increase:
• with increasing age (beyond about 35 years);
• if you smoke. When using a combined hormonal contraceptive like
NuvaRing you are advised to stop smoking. If you are unable to stop
smoking and are older than 35 your doctor may advise you to use a
different type of contraceptive;
• if you are overweight;
• if you have high blood pressure;
• if a member of your immediate family has had a heart attack or stroke at a
young age (less than about 50). In this case you could also have a higher
risk of having a heart attack or stroke;
• if you, or someone in your immediate family, have a high level of fat in the
blood (cholesterol or triglycerides);
• if you get migraines, especially migraines with aura;
• if you have a problem with your heart (valve disorder, disturbance of
the rhythm called atrial fibrillation)
• if you have diabetes.

Laboratory tests
If you are having any blood or urinary test, tell your health care professional
that you are using NuvaRing as it may affect the results of some tests.
2.5 Pregnancy and breast-feeding
NuvaRing must not be used by women who are pregnant, or who think
they may be pregnant. If you get pregnant while using NuvaRing you should
remove the ring and contact your doctor.
If you want to stop NuvaRing because you want to get pregnant, see section
3.5 ‘When you want to stop using NuvaRing’.
NuvaRing is not usually recommended for use during breast-feeding. If you
wish to use NuvaRing while breast-feeding, please seek the advice of your
doctor.
2.6 Driving and using machines
NuvaRing is unlikely to affect your ability to drive or use machines.

3

How to use NuvaRing

You can insert and remove NuvaRing yourself. Your doctor will tell you when
to start using NuvaRing for the first time. The vaginal ring must be put in on
the correct day in your monthly cycle (see section 3.3 ‘When to start with the
first ring’) and left in place for 3 weeks in a row. It is a good habit to regularly
check whether the ring is still in your vagina. After the third week, you take
NuvaRing out and have a one week break. You will usually have your
monthly period during this ring-free interval.
3.1 How to insert and remove NuvaRing
1. Before inserting the ring, check it is not out of date (see section 5 ‘How to
store NuvaRing’).
2. Wash your hands before inserting or removing the ring.
3. Choose the position for inserting that is most comfortable to you, like
standing with one leg up, squatting, or lying down.
4. Remove NuvaRing from its sachet.
5. Hold the ring between your thumb and index finger, press the opposite
sides together and insert the ring into the vagina (see Figures 1– 4).
When NuvaRing is in place you should not feel anything. If you feel
uncomfortable, gently push NuvaRing a bit further into the vagina. The
exact position of the ring inside the vagina is not important.
6. After 3 weeks you remove NuvaRing from the vagina. You can do this by
hooking your index finger under the front rim of the ring or by grasping
the rim and pulling it out (see Figure 5). If you locate the ring in your
vagina, but are unable to remove it, you should contact your doctor.
7. Dispose of the used ring with the normal household waste, preferably
inside the reclosable sachet. Do not flush NuvaRing down the toilet.
Figure 1
Take NuvaRing out of the sachet

Figure 2
Compress the ring

Breast cancer has been found slightly more often in women using combined
pills, but it is not known whether this is caused by the treatment. For
example, it may be that tumours are found more in women on combined pills
because they are examined by the doctor more often. The increased
occurrence of breast cancer becomes gradually less after stopping the
combined pill.

BLOOD CLOTS IN A VEIN

When is the risk of developing a blood clot in a vein highest?
The risk of developing a blood clot in a vein is highest during the first year of
taking a combined hormonal contraceptive for the first time.The risk may also
be higher if you restart taking a combined hormonalcontraceptive (the same
product or a different product) after a break of 4 weeks or more.
After the first year, the risk gets smaller but is always slightly higher than if
you were not using a combined hormonal contraceptive.
When you stop using NuvaRing your risk of a blood clot returns to normal
within a few weeks.
What is the risk of developing a blood clot?
The risk depends on your natural risk of VTE and the type of combined
hormonal contraceptive you are taking.
The overall risk of a blood clot in the leg or lung (DVT or PE) with NuvaRing
is small.
• Out of 10,000 women who are not using any combined hormonal
contraceptive and are not pregnant, about 2 will develop a blood clot in a
year.
• Out of 10,000 women who are using a combined hormonal contraceptive
that contains levonorgestrel, norethisterone, or norgestimate, about 5-7 will
develop a blood clot in a year.
• Out of 10,000 women who are using a combined hormonal contraceptive
that contains norelgestromin, or etonogestrel such as NuvaRing, between
about 6 and 12 women will develop a blood clot in a year.

Page 2

It is important to regularly check your breasts and you should contact your
doctor if you feel any lump. You should also tell your doctor if a close relative
has, or ever had breast cancer (see section 2.2 ‘Warnings and precautions’).
In rare cases, benign liver tumours, and in even fewer cases malignant liver
tumours have been reported in pill users. Contact your doctor if you have
unusual severe abdominal pain.
For users of the combined Pill it has been reported that cancer of the
endometrium (the lining of the womb) and cancer of the ovaries occur less
frequently. This may also be the case for NuvaRing but this has not been
confirmed.
2.3 Children and adolescents
The safety and efficacy of NuvaRing in adolescents under the age of 18 have
not been studied.
2.4 Other medicines and NuvaRing
Always tell the doctor who prescribes NuvaRing which medicines or herbal
products you are already using. Also tell any other doctor or dentist who
prescribes another medicine (or the dispensing pharmacist) that you use
NuvaRing. They can tell you if you need to take additional contraceptive
precautions and, if so, for how long.
Some medicines may cause particular problems when you are using
hormonal contraceptives, such as NuvaRing.






There are medicines that can make NuvaRing less effective in preventing
pregnancy, or can cause unexpected bleeding. These include medicines
used to treat:
• epilepsy (e.g. primidone, phenytoin, barbiturates, carbamazepine,
oxcarbazepine, topiramate, felbamate);
• tuberculosis (e.g. rifampicin);
• HIV infections (e.g. ritonavir);
• other infectious diseases (e.g. griseofulvin and antibiotics with the
exception of amoxicillin and doxycycline, which have been shown not to
influence the hormone release from NuvaRing).
The herbal product St. John’s wort may also stop NuvaRing from working
properly. If you want to use herbal products containing St. John’s wort
while you are already using NuvaRing you should consult your doctor first.
NuvaRing may also interfere with the working of other medicines – such as
ciclosporin and the anti-epileptic lamotrigine.

3.3 When to start with the first ring
• You have not used a hormonal contraceptive during the last month
Insert the first NuvaRing on the first day of your natural cycle (i.e. the first
day of your menstrual period). NuvaRing starts working straight away. You
don’t need to take any other contraceptive precautions. You can also start
NuvaRing between day 2 and day 5 of your cycle, but if you have sexual
intercourse during the first 7 days of NuvaRing use make sure that you
also use an additional contraceptive method (such as a condom). You only
have to follow this advice when you use NuvaRing for the first time.
• You have used a combined Pill during the last month
Start using NuvaRing at the latest the day following the tablet-free period
of your present Pill. If your Pill pack also contains inactive tablets, start
NuvaRing at the latest on the day after the last inactive tablet. If you are
not sure which tablet this is, ask your doctor or pharmacist. Never extend
the hormone-free interval of your current Pill pack beyond its
recommended length. If you have used the Pill consistently and correctly
and if you are sure that you are not pregnant, you can also stop taking the
Pill on any day of your current Pill pack and start using NuvaRing
immediately.
• You have used a transdermal patch during the last month
Start using NuvaRing at the latest the day following your usual patch-free
break. Never extend the patch-free break beyond its recommended length.
If you have used the patch consistently and correctly and if you are sure
that you are not pregnant, you can also stop using the patch on any day
and start using NuvaRing immediately.
• You have used a minipill (progestagen-only pill) during the last month.
You can stop taking the minipill any day and start NuvaRing the next day,
at the same time you would normally have taken your pill. But make sure
you also use an additional contraceptive method (such as a condom) for
the first 7 days of ring use.
• You have used an injectable or implant or a progestagen-releasing
IUD during the last month.
Start using NuvaRing when your next injection is due or on the day that
your implant or your progestagen-releasing IUD is removed. But make sure
you also use an additional contraceptive method (such as a condom) for
the first 7 days of ring use.
• After having a baby.
If you have just had a baby, your doctor may tell you to wait until after your
first normal period before you start using NuvaRing. Sometimes it is
possible to start sooner. Your doctor will advise you. If you are
breast-feeding and want to use NuvaRing, you should discuss this first with
your doctor.
• After a miscarriage or an abortion.
Your doctor will advise you.

If the ring is out for less than 3 hours it will still protect you from pregnancy.
You can rinse the ring with cold to lukewarm water (do not use hot water)
and put it back in. If the ring is out for more than 3 hours, it may not protect
you from pregnancy, see the advice in section 3.4 ‘What to do if… Your
ring has temporarily been out of the vagina’.

Cancer
The information given below was obtained in studies with combined oral
contraceptives and it may also apply to NuvaRing. Information about vaginal
administration of contraceptive hormones (as in NuvaRing) is not available.

What can happen if a blood clot forms in a vein?
• The use of combined hormonal contraceptives has been connected with an
increase in the risk of blood clots in the vein (venous thrombosis).
However, these side effects are rare. Most frequently, they occur in the first
year of use of a combined hormonal contraceptive.
• If a blood clot forms in a vein in the leg or foot it can cause a deep vein
thrombosis (DVT).
• If a blood clot travels from the leg and lodges in the lung it can cause a
pulmonary embolism.
• Very rarely a clot may form in a vein in another organ such as the eye
(retinal vein thrombosis).

If you use NuvaRing as described above, your vaginal bleed will take place
every month on roughly the same days.

Your ring is accidentally expelled from the vagina
NuvaRing may accidentally be expelled from the vagina – for example, if it
has not been inserted properly, while removing a tampon, during sexual
intercourse, during constipation, or if you have a prolapse of the womb.
Therefore, you should regularly check whether the ring is still in your vagina.

If any of the above conditions change while you are using NuvaRing, for
example, you start smoking, a close family member experiences a
thrombosis for no known reason, or you gain a lot of weight, tell your doctor.

Blood clots blocking other blood
vessels

3.2 Three weeks in, one week out
1. Starting with the day you put it in, the vaginal ring must be left in
place without interruption for 3 weeks.
2. After 3 weeks you remove the ring on the same day of the week and at
approximately the same time as it was put in. For example, if you put
NuvaRing in on a Wednesday at about 22.00 h, you should remove the
ring 3 weeks later, on Wednesday, at about 22.00 h.
3. After you have removed the ring, you do not use a ring for 1 week.
During this week a vaginal bleed should occur. Usually this starts 2–3 days
after removal of NuvaRing.
4. Start a new ring exactly after the 1 week interval (again on the same
day of the week and approximately the same time), even if you have
not stopped bleeding.
If the new ring is inserted more than 3 hours too late, the protection from
pregnancy may be reduced. Follow the instructions in section 3.4 ‘What to
do if…You have forgotten to insert a new ring after the ring-free interval’.

3.4 What to do if….

If you have more than one of these conditions or if any of them are
particularly severe, the risk of developing a blood clot may be increased even
more.

Sometimes the symptoms of stroke
can be brief with an almost
immediate and full recovery, but
you should still seek urgent medical
attention as you may be at risk of
another stroke.

• swelling and slight blue

About 6-12 out of 10,000 women

What can happen if a blood clot forms in an artery?
Like a blood clot in a vein, a clot in an artery can cause serious problems.
For example, it can cause a heart attack or a stroke.

Stroke

You can use tampons while using NuvaRing. Insert NuvaRing before
inserting a tampon.

Using spermicides or vaginal yeast products will not reduce the contraceptive
efficacy of NuvaRing.

If any of the above conditions change while you are using NuvaRing, for
example a close family member experiences a thrombosis for no known
reason, or you gain a lot of weight, tell your doctor.

heaviness
sensation of squeezing or fullness
in the chest, arm or below the
breastbone;
fullness, indigestion or choking
feeling;
upper body discom fort radiating
to the back, jaw, throat, arm and
stomach;
sweating, nausea, vomiting or
dizziness;
extreme weakness, anxiety, or
shortness of breath;
rapid or irregular heartbeats
sudden weakness or numbness
of the face, arm or leg, especially
on one side of the body;
sudden confusion, trouble
speaking or understanding;
sudden trouble seeing in one or
both eyes;
sudden trouble walking,
dizziness, loss of balance or
coordination;
sudden, severe or prolonged
headache with no known cause;
loss of consciousness or fainting
with or withou seizure.

About 2 out of 10,000 women

Air travel (>4 hours) may temporarily increase your risk of a blood clot,
particularly if you have some of the other factors listed.

• chest pain, discomfort, pressure,



Women who are not using a
combined hormonal pill/patch/ring
and are not pregnant

The risk of developing a blood clot increases the more conditions you have.

Retinal vein thrombosis
(blood clot in the eye)



Risk of developing a blood clot
in a year

Women using NuvaRing

Symptoms most commonly occur in
one eye:
• immediate loss of vision or
• painless blurring of vision
which can progress to loss of
vision



The risk of having a blood clot will vary according to your personal medical
history (see “Factors that increase your risk of a blood clot” below).

Women using a combined hormonal About 5-7 out of 10,000 women
contraceptive pill containing
levonorgestrel, norethisterone or
norgestimate

If you are unsure, talk to a doctor
as some of these symptoms such
as coughing or being short of
breath may be mistaken for a
milder condition such as a
respiratory tract infection (e.g. a
‘common cold’).





Figure 3
Choose a comfortable position to insert the ring
Insert the ring into the vagina with one hand (Figure 4A), if necessary the
labia may be spread with the other. Push the ring into the vagina until the
ring feels comfortable (Figure 4B). Leave the ring in place for 3 weeks
(Figure 4C).

Figure 4A

Figure 4B

Figure 4C

Figure 5
NuvaRing can be removed by hooking the index
finger under the ring or by grasping the ring
between the index and middle finger and pulling
it out.

Your ring has temporarily been out of the vagina
When it is in the vagina, NuvaRing slowly releases hormones into the body
to prevent pregnancy. If the ring has been out of the vagina for more than
3 hours, it may not protect you from pregnancy. So, the ring must not be
outside the vagina for longer than 3 hours in every twenty-four hour period.
• If the ring has been out of the vagina for less than 3 hours, it will still
protect you from pregnancy. You should put the ring back in as soon as
possible but at the latest within 3 hours.
• If the ring has been out of the vagina, or you suspect that the ring has
been out of the vagina, for more than 3 hours during the 1st and 2nd
week, it may not protect you from pregnancy. Put the ring back in the
vagina as soon as you remember, and leave the ring in place without
interruption for at least 7 days. Use a condom if you have sexual
intercourse during these 7 days. If you are in your 1st week, and you had
sexual intercourse during the past 7 days, there is a possibility you may
be pregnant. In that case contact your doctor.
• If the ring has been out of the vagina, or you suspect that the ring has
been out of the vagina, for more than 3 hours in the 3rd week it may not
protect you from pregnancy. You should discard that ring and choose
between one of the following two options:
1 - Insert a new ring immediately
This will start the next three-week use period. You may not haveyour
period, but breakthrough bleeding and spotting may occur.
2 - Do not insert the ring again. Have your period first and insert a new ring
no later than 7 days from the time the previous ring was removed or fell
out.
You should only chose this option if you have used NuvaRing continuously
during the previous 7 days.
Your ring breaks
Very rarely NuvaRing may break. If you notice that your NuvaRing has
broken, discard it and start with a new ring as soon as possible. Use extra
contraceptive precautions (e.g. a condom) during the next 7 days. If you had
sexual intercourse before you noticed the ring breakage, please contact your
doctor.
You have inserted more than one ring
There have been no reports of serious harmful effects due to an overdose
of the hormones in NuvaRing. If you have accidentally inserted more than
one ring, you may feel sick (nausea) or have vomiting or vaginal bleeding.
Remove excess rings and contact your doctor if these symptoms persist.
You have forgotten to insert a new ring after the ring-free interval
If your ring-free interval was longer than 7 days, put a new ring as soon
as you remember. Use extra contraceptive precautions (such as a condom)
if you have sexual intercourse during the next 7 days. If you had sexual
intercourse in the ring-free interval, there is a possibility you may be
pregnant. In that case contact your doctor immediately. The longer the
ring-free interval, the higher the risk that you have become pregnant.

Ref: 1622/140416/1/F

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Source: Medicines and Healthcare Products Regulatory Agency

Disclaimer: Every effort has been made to ensure that the information provided here is accurate, up-to-date and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. This information has been compiled for use by healthcare practitioners and consumers in the United States. The absence of a warning for a given drug or combination thereof in no way should be construed to indicate that the drug or combination is safe, effective or appropriate for any given patient. If you have questions about the substances you are taking, check with your doctor, nurse or pharmacist.

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