[Ethinyl estradiol 0.120mg and etonogestrel 0.15mg per day]

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Introduction

The generic version of this birth control is Ethinyl estradiol 0.0120 mg and etonogestrel 0.15 mg per day. Similar brand names to this medication are: EluRing®, and Nuvaring® This birth control plan reviews the risks and benefits of the treatment we are recommending. Please make sure to read it and the manufacturer's pamphlet that comes with the medicine. The manufacturer's pamphlet contains the full information on interactions, side effects, and other important information you should know about the medicine before you start.

Active Ingredient

• Ethinyl estradiol (Estrogen analog)
• Etonogestrel (Progestin)
  

Storage

• Your contraceptive vaginal ring should be stored at room temperature between 68°F to 77°F
• Do not store the contraceptive vaginal ring above 86°F
• You can store the contraceptive vaginal ring at room temperature for up to 4 months after you receive it.
• Avoid direct sunlight.
• When discarding the vaginal ring you should place it in the re-closable foil pouch before disposing.
  
  

Instructions

You have stated that you wish to take a contraceptive vaginal ring to prevent pregnancy, and in some instances improve menstrual symptoms. It contains 2 hormones: Etonogestrel (a progestin) and ethinyl estradiol (an estrogen). It works mainly by preventing the release of an egg (ovulation) during your menstrual cycle. This contraceptive vaginal ring should be left in the vagina for 3 weeks and removed for one week to allow a menstrual cycle.

When and How to Start

This treatment can be started on the day of pick up or delivery. You do not need to start this treatment at any particular point within your menstrual cycle. You will need to use a backup method, like condoms, for the first week if you're having reproductive intercourse before pregnancy prevention will begin. Insert the contraceptive vaginal ring in the vagina and keep it in place for 3 weeks (21 days). Ensure the contraceptive vaginal ring stays in your vagina by checking regularly (ex: before and after intercourse). Remove the contraceptive vaginal ring for 1 week (7 days) to allow a menstrual cycle.

You should not use certain female barrier contraceptive methods as they may interfere with correct placement and position. Tampons, spermicides, and vaginal yeast products are safe to use with the contraceptive vaginal ring in place.

Don’t use:

• Vaginal diaphragms
• Cervical caps
• Female/Internal condoms
  
  

Insertion

• Wash and dry your hands before removing the contraceptive vaginal ring from the foil pouch.
• Open the pouch at either notch on the top
• Keep the pouch so you can place your used contraceptive vaginal ring in it before discarding
• Choose a position that’s comfortable for you- lying, squatting, or standing
• Hold the contraceptive vaginal ring between your thumb and index finger and press the sides of the ring together to fold
• Insert the folded contraceptive vaginal ring into your vagina and push it gently into the vagina with your index finger
• The contraceptive vaginal ring does not have to be in an “exact position” for it to work
• The contraceptive vaginal ring may move around slightly within the vagina, this is normal. Most people don’t feel the vaginal ring once it’s in place
• If the contraceptive vaginal ring is uncomfortable you may not have pushed it far enough into the vagina. Use your index finger to gently push in the vaginal ring further.
• If you have severe pain during or after insertion and you cannot find the contraceptive vaginal ring in your vagina, call your in-person healthcare provider right away.
  
  

Removal

• Wash and dry your hands
• Choose a position that’s most comfortable for you—lying, squatting, or standing
• Place your index finger into your vagina and hook it through the contraceptive vaginal ring
• Gently pull downward and forward to remove the vaginal ring and pull it out
• Place the used contraceptive vaginal ring in the resealable foil pouch and discard in a trash can out of reach of children and pets
  
  

How to skip your cycles on the contraceptive vaginal ring

There is no medically indicated reason you need to have a menstrual cycle while you’re on hormonal contraceptives. Monophasic hormonal contraceptives, like your current formulary, have the same consistent daily dosage of estrogen and progesterone to suppress ovulation and provide pregnancy prevention while keeping your uterine lining thin. The cycles that you experience during the week your vaginal ring is removed are called withdrawal bleeds. As the hormones in your body are declining this signals a period, or withdrawal bleed, to allow you to have a cycle. To skip your cycles on the contraceptive vaginal ring you’ll simply leave the vaginal ring in the vagina for 4 weeks instead of removing the ring after 3 weeks. You’ll have enough hormones in the vaginal ring to provide sufficient pregnancy prevention for the full 4 weeks. Skipping your cycles on birth control has no impact on your future fertility or risk for cancers.

How to Manage Breakthrough Bleeding

It’s normal to experience breakthrough bleeding for the first 3 months as your body is adjusting to a new contraceptive formulary, or adjusting from monthly cycles to skipping cycles. Once you start skipping successfully after your third month, if you happen to experience breakthrough bleeding you can manage it the following ways:

• Take Ibuprofen 400 - 800 mg three times daily for 5-10 days
• Remove your vaginal ring for 4 days and discard appropriately. (No back up method is needed if your ring has not been removed for more than 3 hours at a time). After 4 days you will need to insert a new vaginal ring, even if you're still experiencing bleeding, which may result in you requesting an early refill.

Nicotine can also cause unscheduled bleeding with contraceptives as well. If you are a nicotine user consider stopping as this may also improve your breakthrough bleeding episodes. Some people will experience regular interval bleeding (every 2 months, 3 months, 6 months, etc.) which can be managed by allowing a scheduled cycle during those times. Should your bleeding continue to be persistent or intolerable after attempting management with the above recommendations, please reach out to your Wisp provider for further recommendations which may include switching to a new form of contraception.

Switching from a different contraceptive

Oral, patch, or ring contraceptive: Start your new contraceptive vaginal ring the day after your last contraceptive pill, patch, or ring was taken. Use a backup method for one week if any doses were missed.

Injection: Start your vaginal contraceptive ring control up to 15 weeks after your last injection. You should use a backup method for one week if it's been 15 weeks or over since your last injection.

IUD or implant: Start your vaginal contraceptive ring 7 days prior to your IUD or implant removal. If you start your vaginal ring after IUD or implant removal or less than a week before removal ensure to use a backup method for the first week.

Refills

You will automatically be sent a refill every 90 days (subject to a refill visit to help screen for side effects). You may request a refill early by logging into your Account (Subscriptions > Next Refill) or placing a new one-time order. If you decide to stop treatment prior to using your complete subscription please contact us for further guidance.

Allergies/Contraindications

True anaphylactic allergic reactions to hormonal contraception are extremely rare because the active ingredients in these medications mimic naturally occurring hormones in your body. However these medications do have other ingredients that may cause allergic reactions. If you experience any of the symptoms below, you should immediately go to the emergency room or call 911. This list is not all inclusive

• Allergic reaction like: rash, hives, itching, red, swollen, blistered, or peeling skin with or without fever, wheezing, tightness in the chest or throat, trouble breathing, swallowing, or talking, unusual hoarseness, or swelling of the mouth, face, lips, tongue, or throat.
• Liver problems like: dark urine, feeling tired, not hungry, upset stomach or stomach pain, light-colored stools, throwing up, or yellow skin or eyes.
• Signs of a blood clot like: chest pain or pressure, coughing up blood, shortness of breath, swelling, warmth, numbness, change of color, or pain in a leg or arm, trouble speaking, or swallowing There are several contraindications to taking hormonal combined contraception. If you have any of the following conditions please let your doctor know prior to starting medication:
• Adrenal insufficiency
• Current or history of estrogen or progesterone sensitive cancer
• Hepatic tumors
• Pregnancy
• Renal impairment
• Liver disease
• Undiagnosed abnormal uterine bleeding
• Taking hepatitis c drugs (ombitasvir/paritaprevir/ritonavir with or without dasabuvir)
• Prolonged immobilization
• Lupus with unknown of positive antiphospholipid antibody status
• Diabetes with a history of vascular disease or diabetes history >20 years
• Current gallbladder disease without surgical intervention
• Postpartum less than 6 weeks
• Recipient of organ transplant
• Porphyria
• Inflammatory bowel disease
• Advised by a healthcare provider to not take hormones
• Menopause
• Pancreatitis initiated on contraceptives in the past

Use is also contraindicated in women at high risk of having a blood clot or arterial or venous thrombotic diseases including:

• Cerebrovascular disease or history of strokes
• Coronary artery disease or history of heart attack
• Diabetes with a history of vascular disease or diabetes history >20 years
• Current or history of DVT (deep vein thrombosis) or PE (pulmonary Embolism)
• Hyper Coagulopathies (easy to make blood clots) (inherited or acquired),
• Hypertension or high blood pressure (uncontrolled)
• Headaches with focal neurological symptoms or migraines headaches with aura (with or without aura in >35 years old)
• Thrombogenic valvular or rhythm diseases of the heart (eg, subacute bacterial endocarditis with valvular disease or atrial fibrillation)
• 35+ years old who smoke
  
  

Conditions

We have evaluated your health history and the specific health information you provided us, however if anything changes and you develop or discover that one of these conditions applies to you please stop taking this medicine and call or message us immediately.

Pregnancy and Breastfeeding

Use is contraindicated in pregnant women. Combination hormonal contraceptives are used to prevent pregnancy; treatment should be discontinued if pregnancy occurs. In general, the use of combination hormonal contraceptives, when inadvertently used early in pregnancy, have not been associated adverse fetal or maternal effects.

Due to the increased risk of blood clots in legs postpartum, combination hormonal contraceptives should not be started in breastfeeding women <21 days following delivery. The risk of getting a blood clot decreases to population baseline by postpartum day 42. Use of combination hormonal contraceptives in women between 21 and 42 days after delivery should take into consideration the individual woman's risk factors for Getting a blood clot (eg, age ≥35 years, previous blood clot, thrombophilia, immobility, preeclampsia, transfusion at delivery, cesarean delivery, peripartum cardiomyopathy, BMI ≥30 kg/m2, postpartum hemorrhage, or smoking). The risks, benefits, and alternatives to combination hormonal contraception should be evaluated when initiating treatment in breastfeeding women. This should be discussed with your doctor who delivered your child prior to starting treatment.

Combination based birth controls with estrogen may impact your milk supply. If you would like an alternative contraceptive that won't impact your milk supply we recommend a progestin only pill.

Emergency Side Effects

This medicine can cause dangerous and potentially life threatening side effects. If any of the emergency side effects listed in the manufacturer's pamphlet happen to you please stop taking the medicine and call 911 or seek immediate medical help in person. This list can include (but are not limited to):

• Anaphylaxis/anaphylactoid reaction (shortness of breath, difficulty breathing, facial swelling or edema, tongue swelling)
• Jaundice (yellowing of skin and eyes)
• Chest pain
• Visual changes
• Sudden severe headache
• One sided or persistent leg pain
• Weakness or numbness in your extremities
• Trouble speaking
• Toxic shock syndrome (TSS) side effects:
  • Sudden high fever
  • Vomiting
  • Diarrhea
  • Sunburn-like rash
  • Muscle aches
  • Dizziness
  • Fainting or feeling faint with standing
    
    

Other Side Effects

• Vaginal and cervical irritation
• Contraceptive ring slipping out or causing discomfort
• Penis discomfort of th partner
• Edema (swelling in legs)
• Worsening of varicose veins
• Depression
• Melasma (brownish skin, on the forehead, nose, upper lip, and cheeks)
• Amenorrhea (loss of period)
• Breast Changes: breast enlargement, discharge, tenderness, pain
• Increased or decreased Weight
• Changes in menstrual flow
• Abdominal cramps, bloating, nausea, vomiting
• Breakthrough bleeding, spotting, changes in secretions
• Yeast infection
• Change in sexual drive
• Acne
• Headaches
• Bloating
• Vaginal discharge
  
  

Medicines, Supplements, and Foods

We have evaluated your health history and the specific health information you provided us, however if anything changes and you start or discover that you are taking any of the medicines, foods, or supplements listed below call or message us before you take the medicine. Some of these can cause your birth control to be less effective and cause more severe or dangerous side effects. Alternative method of contraceptive (male condoms) Should be used if you are taking these medications (This list is not all inclusive):

• Antibiotics: Rifampin, cefixime, ciprofloxacin, fluconazole, metronidazole nitrofurantoin macrocrystal oral.
• Antifungal medications such as griseofulvin (Gris-PEG®), ketoconazole (Extina®, Nizoral®, Xolegel®)
• Antiretrovirals: ritonavir, ombitasvir, paritaprevir, dasabuvir
• Herbal medications such as St. John’s wort & DIM
• HIV Medications
• Modafinil (Provigil®)
  
  

Accurate Information

We have evaluated the specific health information you provided and are making our recommendations based on it. If you forgot to provide or incorrectly provided that information we may misdiagnose or fail to diagnose conditions that you may have which could affect our recommendation for treatment. If you need to clarify or update any information about your health you can message or call us anytime.

Treatment Failure/Missed Doses

The effectiveness of hormonal contraception is very high when it is consistently used and doses are not missed. Approximately 1 to 3 women out of 100 women may get pregnant using a contraceptive vaginal ring for the first year. The biggest cause of pregnancy is missed doses or not following dosing schedules with the contraceptive vaginal ring.

If your contraceptive vaginal ring breaks or comes out of the vagina

• If the contraceptive vaginal ring breaks and slips out, discard the broken ring and insert a new contraceptive vaginal ring
• If you accidentally pull out your contraceptive vaginal ring while using a tampon, rinse the ring in (not hot) water and insert it again right away

If the contraceptive vaginal ring is expelled from the vagina:

• Less than 3 hours: rinse the ring in (not hot) water and insert it again right away
  
• More than 3 hours:
  • Weeks 1-2: You may not be protected from pregnancy. Reinsert the ring as soon as you remember and use a back-up method, like condoms, for 1 week
  • Week 3: Dispose of the contraceptive vaginal ring, use a back-up method for 7 days, and insert a new ring right away and leave in the vagina for 3 weeks before allowing a menstrual cycle OR allow a ring-free week to allow a menstrual cycle. Make sure to insert a new ring no later than 7 days from the time the previous ring was removed or expelled (you should only use this option if your vaginal ring was in place for a full 7 days prior to removal or expulsion)
    
    

Accepting or Declining Our Recommendation

We are recommending this treatment for you because the potential benefits of treatment outweigh the risks. You should evaluate this information as well as the manufacturer's pamphlet, and any input from your in-person healthcare team, or other relevant information to decide if this treatment plan is appropriate for you. You are free to decline our treatment recommendations.

Alternative Treatment

We have based our recommendation on your specific case and current medical guidelines, but there may be alternative treatments or strategies that may be helpful to you. Some may be more or less effective than what we provide. Some treatments may require an in-person exam or procedure which we can't provide. Message us or talk to your doctor in-person to discuss alternative treatments. Here are some other treatments or strategies that you might consider:

• Implanon implant contraceptives
• Intrauterine device (IUD)
• Intermittent injections
• Transdermal patches
• Oral contraceptive pills
• Male or female condoms
• Diaphragm
• Spermicide
• Sterilization
• Sponge
• Cap
• Diaphragm
• Fertility Awareness Method
• Phexxi
  
  

Share with Your In-Person Healthcare Team

You can access your records anytime. We strongly recommend that you update your in-person doctor, pharmacist, and the rest of your healthcare team to let them know about any new medicines you are taking or other changes in your health. You can also ask us questions anytime and we are happy to help you share any information about your health with your in-person healthcare team.