Key Points for Providers and Client
• Requires keeping a flexible ring in the vagina. It is kept in place all the time, every day and night for 3 weeks, followed by a week with no ring in place.
• Start each new ring on time for greatest effectiveness.
• Bleeding changes are common but not harmful. Typically, irregular bleeding for the first few months and then lighter and more regular bleeding.
What Is the Combined Vaginal Ring?
• A flexible ring placed in the vagina.
• Continuously releases 2 hormones—a progestin and an estrogen, like the natural hormones progesterone and estrogen in a woman’s body—from inside the ring. Hormones are absorbed through the wall of the vagina directly into the bloodstream.
• The ring is kept in place for 3 weeks, then removed for the fourth week. During this fourth week the woman will have monthly bleeding.
• Also called NuvaRing.
• Works primarily by preventing the release of eggs from the ovaries (ovulation).
Effectiveness depends on the user: Risk of pregnancy is greatest when a woman is late to start a new ring.
• The combined vaginal ring is new, and research on effectiveness is limited. Effectiveness rates in clinical trials of the vaginal ring suggest that it may be more effective than combined oral contraceptives, both as commonly used and with consistent and correct use.
Return of fertility after ring use is stopped: No delay
Protection against sexually transmitted infections: None
Side Effects, Health Benefits, and Health Risks
Some users report the following:
• Changes in monthly bleeding, including:
— Lighter bleeding and fewer days of bleeding
— Irregular bleeding
— Infrequent bleeding
— Prolonged bleeding
— No monthly bleeding
• Irritation, redness, or inflammation of the vagina (vaginitis)
• White vaginal discharge
Known Health Benefits and Health Risks
Long-term studies of the vaginal ring are limited, but researchers expect that its health benefits and risks are like those of combined oral contraceptives.
Medical eligibility criteria, guidelines for when to start and helping continuing users are the same for the combined ring as for combined oral contraceptives.
Providing the Combined Vaginal Ring
Explaining How to Use
Explain How to insert the ring
• She can choose the position most comfortable for her—for example, standing with one leg up, squatting, or lying down.
• She should press opposite sides of the ring together and gently push the folded ring entirely inside the vagina.
• The exact position is not important, but inserting it deeply helps it to stay in place, and she is less likely to feel it. The muscles of the vagina naturally keep the ring in place.
Explain that the ring must be left in place for 3 weeks
• She should keep the ring in place all the time, every day and night for 3 weeks.
• She can take the ring out at the end of the third week and dispose of it in a waste receptacle.
She should take out the ring for the fourth week
• To remove the ring, she should hook her index finger inside it, or squeeze the ring between her index and middle fingers, and pull it out.
• She will probably have monthly bleeding this week.
• If she forgets and leaves the ring in for as long as a fourth week, no special action is needed.
Ring should never be left out for more than 3 hours until the fourth week
• The ring can be removed for sex, cleaning, or other reasons, although removing it is not necessary.
• If the ring slips out, she should rinse it in clean water and immediately reinsert it.
Supporting the User
Instructions for Late Replacement or Removal
Left ring out for more than 3 hours during weeks 1 or 2?
• Put the ring back in as soon as possible. Use a backup method* for the next 7 days.
Left ring out for more than 3 hours during week 3?
• Stop the current cycle and discard the ring.
• Insert a new ring immediately and keep it in place for 3 weeks, starting a new cycle. Use a backup method for the next 7 days.
(Another option, if the ring was used continuously and correctly for the past 7 days: Leave the ring out and make the next 7 days the week with no ring. After those 7 days, insert a new ring, starting a new cycle, and keep it in place for 3 weeks. Use a backup method for the first 7 days with the new ring.)
Waited more than 7 days before inserting a new ring, or kept ring in longer than 4 weeks?
• Insert a new ring as soon as possible and begin a new 4-week cycle. Use a backup method for the first 7 days of ring use.
• Also, if a new ring was inserted 3 or more days late (ring was left out for 10 days or more in a row) and unprotected sex took place in the past 5 days, consider taking emergency contraceptive pills.