Etonogestrel/​Ethinyl Estradiol

DEA Class; Rx

Common Brand Names; NuvaRing, EluRyng

Indicated for use by females of reproductive age

Indicated for routine contraception under the following conditions.

• Switching from a combination oral contraceptive.
• Switching from a progestin-only method.
  Following complete first trimester abortion.

  Following delivery or second trimester abortion.

Documented hypersensitivity

Arterial thromboembolic disease (stroke, MI), thrombophlebitis, DVT/PE, thrombogenic valvular disease

Estrogen-dependent neoplasia (current or history of)

Cerebrovascular disease, coronary artery disease

Headaches with focal neurological symptoms

Liver disease, liver tumors

Undiagnosed abnormal vaginal bleeding

Uncontrolled hypertension

Women >35 years who smoke

Major surgery with prolonged immobilization

Diabetes mellitus with vascular involvement, jaundice with prior oral contraceptive use

Breast cancer or other estrogen-or progestin-sensitive cancer,now or in the past

Use of hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, due to potential for ALT elevations

• Vaginitis (13.8%)
• Headache (including migraine) (11.2%)
• Mood changes (6.4%)
• Device-related events (eg, expulsion/discomfort/foreign body sensation) (6.3%)
• Nausea/vomiting (5.9%)
• Vaginal discharge (5.7%)
• Increased weight (4.9%)
• Vaginal discomfort (4%)
• Breast pain/discomfort/tenderness (3.8%)
• Dysmenorrhea (3.5%)
• Abdominal pain (3.2%)
• Acne (2.4%)
• Decreased libido (2%)
• Immune system disorders: Hypersensitivity (anaphylaxis and angioedema)
• Nervous system disorders: Stroke/cerebrovascular accident
• Vascular disorders: Arterial events (including arterial thromboembolism and myocardial infarction), aggravation of varicose veins
• Skin and subcutaneous tissue disorders: urticaria, chloasma
• Reproductive system and breast disorders: penile disorders, including local reactions on penis (in male partners of women using NuvaRing), galactorrhea
• Injury, poisoning and procedural complications: Vaginal injury (including associated pain, discomfort, and bleeding) associated with ring breakage

Avoid using diaphragm concomitantly; may interfere with ring placement

Family history of breast cancer and or DVT/PE

Use caution in current/history of depression, endometriosis, DM, HTN, bone mineral density changes, renal/hepatic impairment, bone metabolic disease, SLE; conditions exacerbated by fluid retention (eg, migraine, asthma, epilepsy)

Known risk factors for VTE include smoking, obesity, and family history of VTE, in addition to other factors that contraindicate use of CHCs; stop use if arterial thrombotic or venous thromboembolic event (VTE) occurs or if there is unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions; evaluate for retinal vein thrombosis immediately

The risk of VTE is highest during first year of CHC use and after restarting a CHC following a break of at least four weeks; risk of VTE due to CHCs gradually disappears after use is discontinued

Discontinue if the following develop jaundice, visual problems (may cause contact lens intolerance), migraine with unusual severity, significant blood pressure increase, severe depression, increased risk of thromboembolic complications after surgery

Discontinue 4 week before major surgery or prolonged immobilization

Discontinue if an arterial thrombotic or venous thromboembolic event occurs

Estrogens may cause retinal vascular thrombosis; discontinue therapy if visual disturbances occur including migraine, loss of vision, diplopia, or proptosis

Patients on warfarin, oral anticoagulants (increase in anticoagulant dose may be warranted)

Increased risk of cervical cancer with OCP use, however HPV remains as main risk factor for this cancer, evidence suggests long-term use of OCPs, 5 or more years, may be associated with increased risk

Increased risk of liver cancer with OCP use; risk increases with longer duration of OCP use

Combination of hormonal contraceptives may affect lipoprotein levels and serum triglycerides

Use of CHCs may worsen existing gallbladder disease; past history of CHC-related cholestasis predicts an increased risk with subsequent CHC use; women with a history of pregnancy-related cholestasis may be at increased risk for CHC-related cholestasis

Extensive epidemiological studies have revealed no increased risk of birth defects in women who have used oral contraceptives prior to pregnancy; studies also do not suggest a teratogenic effect, particularly insofar as cardiac anomalies and limb reduction defects are concerned, when taken inadvertently during early pregnancy

Small amounts of oral contraceptive steroids identified in the milk of nursing mothers, and a few adverse effects on child reported, including jaundice and breast enlargement; in addition, oral contraceptives given in postpartum period may interfere with lactation by decreasing quantity and quality of breast milk