Etonogestrel and Ethinyl Estradiol Vaginal Ring

Etonogestrel and Ethinyl Estradiol Vaginal Ring
Black Box Warning
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]

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Black Box Warning

WARNING: CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS See full prescribing information for complete Boxed Warning. CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS: Cigarette smoking increases the risk of serious cardiovascular events from combination hormonal contraceptive (CHC) use. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked. For this reason, CHCs, including NuvaRing, should not be used by women who are over 35 years of age and smoke.

Overview

Etonogestrel and Ethinyl Estradiol Vaginal Ring is an estrogen and progestin combination that is FDA approved for the {{{indicationType}}} of to prevent pregnancy. There is a Black Box Warning for this drug as shown here. Common adverse reactions include mood disorder, vaginal discharge, vaginitis.

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

How to Use Etonogestrel and Ethinyl Estradiol Vaginal Ring

• To achieve maximum contraceptive effectiveness, etonogestrel and ethinyl estradiol vaginal ring must be used as directed . One etonogestrel and ethinyl estradiol vaginal ring is inserted in the vagina. The ring is to remain in place continuously for three weeks. It is removed for a one-week break, during which a withdrawal bleed usually occurs. A new ring is inserted one week after the last ring was removed.
• The user can choose the insertion position that is most comfortable to her, for example, standing with one leg up, squatting, or lying down. The ring is to be compressed and inserted into the vagina. The exact position of etonogestrel and ethinyl estradiol vaginal ring inside the vagina is not critical for its function. The vaginal ring must be inserted on the appropriate day and left in place for three consecutive weeks. This means that the ring should be removed three weeks later on the same day of the week as it was inserted and at about the same time.
• Etonogestrel and ethinyl estradiol vaginal ring can be removed by hooking the index finger under the forward rim or by grasping the rim between the index and middle finger and pulling it out. The used ring should be placed in the sachet (foil pouch) and discarded in a waste receptacle out of the reach of children and pets (do not flush in toilet).
• After a one-week break, during which a withdrawal bleed usually occurs, a new ring is inserted on the same day of the week as it was inserted in the previous cycle. The withdrawal bleed usually starts on Day 2-3 after removal of the ring and may not have finished before the next ring is inserted. In order to maintain contraceptive effectiveness, the new ring must be inserted exactly one week after the previous one was removed even if menstrual bleeding has not finished.

How to Start Using Etonogestrel and Ethinyl Estradiol vaginal ring

Consider the possibility of ovulation and conception prior to the first use of etonogestrel and ethinyl estradiol vaginal ring.

• No Hormonal Contraceptive Use in the Preceding Cycle: The woman should insert etonogestrel and ethinyl estradiol vaginal ring on the first day of her menstrual bleeding. etonogestrel and ethinyl estradiol vaginal ring may also be started on Days 2-5 of the woman's cycle, but in this case a barrier method, such as male condoms with spermicide, should be used for the first seven days of etonogestrel and ethinyl estradiol vaginal ring use in the first cycle.
• Changing From a Combined Hormonal Contraception (CHC): The woman may switch from her previous CHC on any day, but at the latest on the day following the usual hormone-free interval, if she has been using her hormonal method consistently and correctly, or if it is reasonably certain that she is not pregnant.
• Changing From a Progestin-Only Method (progestin-only pill [POP], Implant, or Injection or a Progestin-Releasing Intrauterine System [IUS]): The woman may switch from the POP on any day; instruct her to start using etonogestrel and ethinyl estradiol vaginal ring on the day after she took her last POP. She should switch from an implant or the IUS on the day of its removal, and from an injectable on the day when the next injection would be due. In all of these cases, the woman should use an additional barrier method such as a male condom with spermicide, for the first seven days.
• Use after Abortion or Miscarriage: The woman may start using etonogestrel and ethinyl estradiol vaginal ring within the first five days following a complete first trimester abortion or miscarriage, and she does not need to use an additional method of contraception. If use of etonogestrel and ethinyl estradiol vaginal ring is not started within five days following a first trimester abortion or miscarriage, the woman should follow the instructions for "No Hormonal Contraceptive Use in the Preceding Cycle". In the meantime, she should be advised to use a non-hormonal contraceptive method.

• Start etonogestrel and ethinyl estradiol vaginal ring no earlier than four weeks after a second trimester abortion or miscarriage, due to the increased risk of thromboembolism.

• Following Childbirth: The use of etonogestrel and ethinyl estradiol vaginal ring may be initiated no sooner than four weeks postpartum in women who elect not to breastfeed, due to the increased risk of thromboembolism in the postpartum period.

• Advise women who are breastfeeding not to use etonogestrel and ethinyl estradiol vaginal ring but to use other forms of contraception until the child is weaned.
• If a woman begins using etonogestrel and ethinyl estradiol vaginal ring postpartum, instruct her to use an additional method of contraception, such as male condoms with spermicide, for the first seven days. If she has not yet had a period, consider the possibility of ovulation and conception occurring prior to initiation of etonogestrel and ethinyl estradiol vaginal ring.

Deviations from the Recommended Regimen

• To prevent loss of contraceptive efficacy, advise women not to deviate from the recommended regimen. Etonogestrel and ethinyl estradiol vaginal ring should be left in the vagina for a continuous period of three weeks.
• Inadvertent Removal or Expulsion: Etonogestrel and ethinyl estradiol vaginal ring can be accidentally expelled, for example, while removing a tampon, during intercourse, or with straining during a bowel movement. Etonogestrel and ethinyl estradiol vaginal ring should be left in the vagina for a continuous period of three weeks. If the ring is accidentally expelled and is left outside of the vagina for less than three hours, contraceptive efficacy is not reduced. Etonogestrel and ethinyl estradiol vaginal ring can be rinsed with cool to lukewarm (not hot) water and reinserted as soon as possible, but at the latest within three hours. If etonogestrel and ethinyl estradiol vaginal ring is lost, a new vaginal ring should be inserted and the regimen should be continued without alteration.
• If etonogestrel and ethinyl estradiol vaginal ring is out of the vagina for more than three continuous hours:

• During Weeks 1 and 2: Contraceptive efficacy may be reduced. The woman should reinsert the ring as soon as she remembers. A barrier method such as condoms with spermicides must be used until the ring has been used continuously for seven days.
• During Week 3: The woman should discard that ring. One of the following two options should be chosen:

1. Insert a new ring immediately. Inserting a new ring will start the next three-week use period. The woman may not experience a withdrawal bleed from her previous cycle. However, breakthrough spotting or bleeding may occur.
2. Insert a new ring no later than seven days from the time the previous ring was removed or expelled, during which time she may have a withdrawal bleed. This option should only be chosen if the ring was used continuously for at least seven days prior to inadvertent removal/expulsion.

• In either case, a barrier method such as condoms with spermicides must be used until the new ring has been used continuously for seven days.

• Prolonged Ring-Free Interval: If the ring-free interval has been extended beyond one week, consider the possibility of pregnancy, and an additional method of contraception, such as male condoms with spermicide, MUST be used until etonogestrel and ethinyl estradiol vaginal ring has been used continuously for seven days.
• Prolonged Use of Etonogestrel and Ethinyl Estradiol Vaginal Ring : If etonogestrel and ethinyl estradiol vaginal ring has been left in place for up to one extra week (i.e., up to four weeks total), the woman will remain protected. Etonogestrel and ethinyl estradiol vaginal ring should be removed and the woman should insert a new ring after a one-week ring-free interval.
• If etonogestrel and ethinyl estradiol vaginal ring has been left in place for longer than four weeks, instruct the woman to remove the ring, and rule out pregnancy. If pregnancy is ruled out, etonogestrel and ethinyl estradiol vaginal ring may be restarted, and an additional method of contraception, such as male condoms with spermicide, must be used until a new etonogestrel and ethinyl estradiol vaginal ring has been used continuously for seven days.
• Ring Breakage: There have been reported cases of etonogestrel and ethinyl estradiol vaginal ring disconnecting at the weld joint. This is not expected to affect the contraceptive effectiveness of etonogestrel and ethinyl estradiol vaginal ring. In the event of a disconnected ring, vaginal discomfort or expulsion (slipping out) is more likely to occur. If a woman discovers that her etonogestrel and ethinyl estradiol vaginal ring has disconnected, she should discard the ring and replace it with a new ring.

In the Event of a Missed Menstrual Period

1. If the woman has not adhered to the prescribed regimen (etonogestrel and ethinyl estradiol vaginal ring has been out of the vagina for more than three hours or the preceding ring-free interval was extended beyond one week), consider the possibility of pregnancy at the time of the first missed period and discontinue etonogestrel and ethinyl estradiol vaginal ring use if pregnancy is confirmed.
2. If the woman has adhered to the prescribed regimen and misses two consecutive periods, rule out pregnancy.
3. If the woman has retained one etonogestrel and ethinyl estradiol vaginal ring for longer than four weeks, rule out pregnancy.

Use with Other Vaginal Products

• Etonogestrel and ethinyl estradiol vaginal ring may interfere with the correct placement and position of a diaphragm. A diaphragm is therefore not recommended as a back-up method with etonogestrel and ethinyl estradiol vaginal ring use.
• Pharmacokinetic data show that the use of tampons has no effect on the systemic absorption of the hormones released by etonogestrel and ethinyl estradiol vaginal ring.

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Etonogestrel and Ethinyl Estradiol Vaginal Ring in adult patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Etonogestrel and Ethinyl Estradiol Vaginal Ring in adult patients.

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

There is limited information regarding Etonogestrel and Ethinyl Estradiol Vaginal Ring FDA-Labeled Indications and Dosage (Pediatric) in the drug label.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Etonogestrel and Ethinyl Estradiol Vaginal Ring in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Etonogestrel and Ethinyl Estradiol Vaginal Ring in pediatric patients.

Contraindications

• A high risk of arterial thrombosis or venous thrombosis. Examples include women who are known to:

• Smoke, if over age 35.
• Have deep vein thrombosis or pulmonary embolism, now or in the past.
• Have cerebrovascular disease.
• Have coronary artery disease.
• Have thrombogenic valvular or thrombogenic rhythm diseases of the heart (for example, subacute bacterial endocarditis with valvular disease, or atrial fibrillation).
• Have inherited or acquired hypercoagulopathies.
• Have uncontrolled hypertension.
• Have diabetes mellitus with vascular disease.
• Have headaches with focal neurological symptoms or migraine headaches with aura.

• Women over age 35 with any migraine headaches.

• Liver tumors, benign or malignant or liver disease.
• Undiagnosed abnormal uterine bleeding.
• Pregnancy, because there is no reason to use CHCs during pregnancy.
• Breast cancer or other estrogen- or progestin-sensitive cancer, now or in the past.
• Hypersensitivity to any of the components of etonogestrel and ethinyl estradiol vaginal ring.

Warnings

WARNING: CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS See full prescribing information for complete Boxed Warning. CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS: Cigarette smoking increases the risk of serious cardiovascular events from combination hormonal contraceptive (CHC) use. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked. For this reason, CHCs, including NuvaRing, should not be used by women who are over 35 years of age and smoke.

Thromboembolic Disorders and Other Vascular Problems

• Stop etonogestrel and ethinyl estradiol vaginal ring use if an arterial thrombotic or venous thromboembolic event (VTE) occurs. Stop etonogestrel and ethinyl estradiol vaginal ring use if there is unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions. Evaluate for retinal vein thrombosis immediately.
• If feasible, stop etonogestrel and ethinyl estradiol vaginal ring at least four weeks before and through two weeks after major surgery or other surgeries known to have an elevated risk of thromboembolism, and during and following prolonged immobilization.
• Start etonogestrel and ethinyl estradiol vaginal ring no earlier than 4 weeks after delivery, in women who are not breastfeeding. The risk of postpartum thromboembolism decreases after the third postpartum week, whereas the risk of ovulation increases after the third postpartum week.
• The use of CHCs increases the risk of VTE. Known risk factors for VTE include smoking, obesity, and family history of VTE, in addition to other factors that contraindicate use of CHCs.
• Two epidemiologic studies1, 2, 3 that assessed the risk of VTE associated with the use of etonogestrel and ethinyl estradiol vaginal ring are described below.
• In these studies, which were required or sponsored by regulatory agencies, etonogestrel and ethinyl estradiol vaginal ring users had a risk of VTE similar to COC users (see table below for adjusted hazard ratios). A large prospective, observational study, the Transatlantic Active Surveillance on Cardiovascular Safety of etonogestrel and ethinyl estradiol vaginal ring (TASC), investigated the risk of VTE for new users, and women who were switching to or restarting etonogestrel and ethinyl estradiol vaginal ring or COCs in a population that is representative of routine clinical users. The women were followed for 24 to 48 months. The results showed a similar risk of VTE among etonogestrel and ethinyl estradiol vaginal ring users (VTE incidence 8.3 per 10,000 WY) and women using COCs (VTE incidence 9.2 per 10,000 WY). For women using COCs that did not contain the progestins desogestrel (DSG) or gestodene (GSD), VTE incidence was 8.9 per 10,000 WY.
• A retrospective cohort study using data from 4 health plans in the US (FDA-funded Study in Kaiser Permanente and Medicaid databases) showed the VTE incidence for new users of etonogestrel and ethinyl estradiol vaginal ring to be 11.4 events per 10,000 WY, for new users of a levonorgestrel (LNG)-containing COC 9.2 events per 10,000 WY, and for users of other COCs available during the course of the study¹ 8.2 events per 10,000 WY.

This image is provided by the National Library of Medicine.

• An increased risk of thromboembolic and thrombotic disease associated with the use of CHCs is well-established. Although the absolute VTE rates are increased for users of CHCs compared to non-users, the rates associated with pregnancy are even greater, especially during the post-partum period (see figure below).
• The frequency of VTE in women using CHCs has been estimated to be 3 to 12 cases per 10,000 women-years.
• The risk of VTE is highest during the first year of CHC use and after restarting a CHC following a break of at least four weeks. The risk of VTE due to CHCs gradually disappears after use is discontinued.
• Figure 1 shows the risk of developing a VTE for women who are not pregnant and do not use CHCs, for women who use CHCs, for pregnant women, and for women in the postpartum period. To put the risk of developing a VTE into perspective: If 10,000 women who are not pregnant and do not use CHCs are followed for one year, between 1 and 5 of these women will develop a VTE.

This image is provided by the National Library of Medicine.

• Several epidemiology studies indicate that third generation oral contraceptives, including those containing desogestrel (etonogestrel, the progestin in etonogestrel and ethinyl estradiol vaginal ring, is the biologically active metabolite of desogestrel), may be associated with a higher risk of VTE than oral contraceptives containing other progestins. Some of these studies indicate an approximate two-fold increased risk. However, data from other studies have not shown this two-fold increase in risk.
• Use of CHCs also increases the risk of arterial thromboses such as strokes and myocardial infarctions, especially in women with other risk factors for these events. CHCs have been shown to increase both the relative and attributable risks of cerebrovascular events (thrombotic and hemorrhagic strokes). In general, the risk is greatest among older (>35 years of age), hypertensive women who also smoke.
• Use etonogestrel and ethinyl estradiol vaginal ring with caution in women with cardiovascular disease risk factors.

¹Includes low-dose COCs containing the following progestins: norgestimate, norethindrone, or levonorgestrel.

Toxic Shock Syndrome (TSS)

• Cases of TSS have been reported by etonogestrel and ethinyl estradiol vaginal ring users. TSS has been associated with tampons and certain barrier contraceptives, and, in some cases the etonogestrel and ethinyl estradiol vaginal ring users were also using tampons. A causal relationship between the use of etonogestrel and ethinyl estradiol vaginal ring and TSS has not been established. If a patient exhibits signs or symptoms of TSS, consider the possibility of this diagnosis and initiate appropriate medical evaluation and treatment.

Liver Disease

Impaired Liver Function

• Do not use etonogestrel and ethinyl estradiol vaginal ring in women with liver disease such as acute viral hepatitis or severe (decompensated) cirrhosis of the liver. Acute or chronic disturbances of liver function may necessitate the discontinuation of CHC use until markers of liver function return to normal and CHC causation has been excluded. Discontinue etonogestrel and ethinyl estradiol vaginal ring use if jaundice develops.

Liver Tumors

• Etonogestrel and ethinyl estradiol vaginal ring is contraindicated in women with benign and malignant liver tumors. Hepatic adenomas are associated with CHC use. An estimate of the attributable risk is 3.3 cases per 100,000 CHC users. Rupture of hepatic adenomas may cause death through intra-abdominal hemorrhage.
• Studies have shown an increased risk of developing hepatocellular carcinoma in long term (>8 years) CHC users. However, the attributable risk of liver cancers in CHC users is less than one case per million users.

High Blood Pressure

• Etonogestrel and ethinyl estradiol vaginal ring is contraindicated in women with uncontrolled hypertension or hypertension with vascular disease. For women with well-controlled hypertension, monitor blood pressure and stop etonogestrel and ethinyl estradiol vaginal ring use if blood pressure rises significantly.
• An increase in blood pressure has been reported in women using CHCs and this increase is more likely in older women and with extended duration of use. The incidence of hypertension increases with increasing concentrations of progestin.

Vaginal Use

• Etonogestrel and ethinyl estradiol vaginal ring may not be suitable for women with conditions that make the vagina more susceptible to vaginal irritation or ulceration. Vaginal/cervical erosion or ulceration in women using etonogestrel and ethinyl estradiol vaginal ring has been reported. In some cases, the ring adhered to vaginal tissue, necessitating removal by a healthcare provider.
• Some women are aware of the ring on occasion during the 21 days of use or during intercourse, and sexual partners may feel etonogestrel and ethinyl estradiol vaginal ring in the vagina.

Gallbladder Disease

• Studies suggest a small increased relative risk of developing gallbladder disease among CHC users. Use of CHCs may also worsen existing gallbladder disease.
• A 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 an increased risk for CHC-related cholestasis.

Carbohydrate and Lipid Metabolic Effects

• Carefully monitor prediabetic and diabetic women who are using etonogestrel and ethinyl estradiol vaginal ring. CHCs may decrease glucose tolerance.
• Consider alternative contraception for women with uncontrolled dyslipidemia. Some women will have adverse lipid changes while on CHCs.
• Women with hypertriglyceridemia, or a family history thereof, may be at an increased risk of pancreatitis when using CHCs.

Headache

• If a woman using etonogestrel and ethinyl estradiol vaginal ring develops new headaches that are recurrent, persistent, or severe, evaluate the cause and discontinue etonogestrel and ethinyl estradiol vaginal ring if indicated.
• Consider discontinuation of etonogestrel and ethinyl estradiol vaginal ring in the case of an increased frequency or severity of migraine during CHC use (which may be prodromal of a cerebrovascular event).

Bleeding Irregularities and Amenorrhea

Unscheduled Bleeding and Spotting

• Unscheduled bleeding (breakthrough or intracyclic) bleeding and spotting sometimes occur in women using CHCs, especially during the first three months of use. If bleeding persists or occurs after previously regular cycles, check for causes such as pregnancy or malignancy. If pathology and pregnancy are excluded, bleeding irregularities may resolve over time or with a change to a different CHC.
• Bleeding patterns were evaluated in three large clinical studies. In the North American study (US and Canada, N=1,177), the percentages of subjects with breakthrough bleeding/spotting ranged from 7.2% to 11.7% during cycles 1-13. In the two non-US studies, the percentages of subjects with breakthrough bleeding/spotting ranged from 2.6% to 6.4% (Europe, N=1,145) and from 2.0% to 8.7% (Europe, Brazil, Chile, N=512).

Amenorrhea and Oligomenorrhea

• If scheduled (withdrawal) bleeding does not occur, consider the possibility of pregnancy. If the patient has not adhered to the prescribed dosing schedule, consider the possibility of pregnancy at the time of the first missed period and take appropriate diagnostic measures.
• Occasional missed periods may occur with the appropriate use of etonogestrel and ethinyl estradiol vaginal ring. In the clinical studies, the percent of women who did not have withdrawal bleeding in a given cycle ranged from 0.3% to 3.8%.
• If the patient has adhered to the prescribed regimen and misses two consecutive periods, rule out pregnancy.
• Some women may experience amenorrhea or oligomenorrhea after discontinuing CHC use, especially when such a condition was pre-existent.

Inadvertent Urinary Bladder Insertion

There have been reports of inadvertent insertions of etonogestrel and ethinyl estradiol vaginal ring into the urinary bladder, which required cystoscopic removal. Assess for ring insertion into the urinary bladder in etonogestrel and ethinyl estradiol vaginal ring users who present with persistent urinary symptoms and are unable to locate the ring.

CHC Use Before or During Early Pregnancy

• 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 in so far as cardiac anomalies and limb reduction defects are concerned, when taken inadvertently during early pregnancy. Discontinue etonogestrel and ethinyl estradiol vaginal ring if pregnancy is confirmed.

Depression

• Carefully observe women with a history of depression and discontinue etonogestrel and ethinyl estradiol vaginal ring use if depression recurs to a serious degree.

Carcinoma of the Breasts and Cervix

• Etonogestrel and ethinyl estradiol vaginal ring is contraindicated in women who currently have or have had breast cancer because breast cancer is a hormonally-sensitive tumor.
• There is substantial evidence that CHCs do not increase the incidence of breast cancer. Although some past studies have suggested that CHCs might increase the incidence of breast cancer, more recent studies have not confirmed such findings.
• Some studies suggest that CHCs are associated with an increase in the risk of cervical cancer or intraepithelial neoplasia. However, there is controversy about the extent to which these findings may be due to differences in sexual behavior and other factors.

Effect on Binding Globulins

• The estrogen component of CHCs may raise the serum concentrations of thyroxine-binding globulin, sex hormone-binding globulin, and cortisol-binding globulin. The dose of replacement thyroid hormones or cortisol therapy may need to be increased.

Monitoring

• A woman who is using etonogestrel and ethinyl estradiol vaginal ring should have a yearly visit with her healthcare provider for a blood pressure check and for other indicated healthcare.

Hereditary Angioedema

• In women with hereditary angioedema, exogenous estrogens may induce or exacerbate symptoms of angioedema.

Chloasma

• Chloasma may occasionally occur, especially in women with a history of chloasma gravidarum. Women with a tendency to chloasma should avoid exposure to the sun or ultraviolet radiation while using etonogestrel and ethinyl estradiol vaginal ring.

Adverse Reactions

Clinical Trials Experience

The following serious adverse reactions with the use of CHCs are discussed elsewhere.

• Serious cardiovascular events and stroke (see Etonogestrel and Ethinyl Estradiol Vaginal Ring#Boxed Warning

Postmarketing Experience

The following adverse reactions have been identified during post-approval use of etonogestrel and ethinyl estradiol vaginal ring. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

• Immune system disorders: hypersensitivity
• 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

Drug Interactions

Consult the labeling of all concurrently-used drugs to obtain further information about interactions with hormonal contraceptives or the potential for enzyme alterations.

Effects of Other Drugs on CHCs

• Substances decreasing the plasma concentrations of CHCs and potentially diminishing the effectiveness of CHCs
• Drugs or herbal products that induce certain enzymes, including cytochrome P450 3A4 (CYP3A4), may decrease the plasma concentrations of CHCs and potentially diminish the effectiveness of CHCs or increase breakthrough bleeding. Some drugs or herbal products that may decrease the effectiveness of hormonal contraceptives include: phenytoin, barbiturates, carbamazepine, bosentan, felbamate, griseofulvin, oxcarbazepine, rifampicin, topiramate, rifabutin, rufinamide, aprepitant, and products containing St. John's wort. Interactions between CHCs and other drugs may lead to breakthrough bleeding and/or contraceptive failure. Counsel women to use an alternative method of contraception or a back-up method when enzyme inducers are used with etonogestrel and ethinyl estradiol vaginal ring, and to continue back-up contraception for 28 days after discontinuing the enzyme inducer to ensure contraceptive reliability.
• The serum concentrations of etonogestrel and ethinyl estradiol were not affected by concomitant administration of oral amoxicillin or doxycycline in standard dosages during 10 days of antibiotic treatment. The effects of other antibiotics on etonogestrel or ethinyl estradiol concentrations have not been evaluated.
• Substances increasing the plasma concentrations of CHCs
• Co-administration of atorvastatin and certain CHCs containing ethinyl estradiol increase AUC values for ethinyl estradiol by approximately 20-25%. Ascorbic acid and acetaminophen may increase plasma ethinyl estradiol concentrations, possibly by inhibition of conjugation. CYP3A4 inhibitors such as itraconazole, voriconazole, fluconazole, grapefruit juice, or ketoconazole may increase plasma hormone concentrations. Co-administration of vaginal miconazole nitrate and etonogestrel and ethinyl estradiol vaginal ring increases the serum concentrations of etonogestrel and ethinyl estradiol by up to 40%.
• Human immunodeficiency virus (HIV)/ Hepatitis C Virus (HCV) protease inhibitors and non-nucleoside reverse transcriptase inhibitors:
• Significant changes in the plasma concentrations of the estrogen and /or progestin have been noted in some cases of co-administration with HIV protease inhibitors decrease [(e.g., nelfinavir, ritonavir, darunavir/ritonavir, (fos)amprenavir/ritonavir, lopinavir/ritonavir, and tipranavir/ritonavir) or increase (e.g., indinavir and atazanavir/ritonavir)] /HCV protease inhibitors [decrease (e.g., boceprevir and telaprevir)] or with non-nucleoside reverse transcriptase inhibitors [decrease (e.g., nevirapine) or increase (e.g., etravirine)].

Effects of CHCs on Other Drugs

• CHCs containing ethinyl estradiol may inhibit the metabolism of other compounds (e.g., cyclosporine, prednisolone, theophylline, tizanidine, and voriconazole) and increase their plasma concentrations. CHCs have been shown to decrease plasma concentrations of acetaminophen, clofibric acid, morphine, salicylic acid and temazepam. A significant decrease in the plasma concentrations of lamotrigine has been shown, likely due to induction of lamotrigine glucuronidation. This may reduce seizure control, therefore, dosage adjustments of lamotrigine may be necessary.
• Women on thyroid hormone replacement therapy may need increased doses of thyroid hormone because serum concentrations of thyroid-binding globulin increase with use of CHCs.

Interference with Laboratory Tests

• The use of contraceptive steroids may influence the results of certain laboratory tests, such as coagulation factors, lipids, glucose tolerance, and binding proteins.

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA):

• There is little or no increased risk of birth defects in women who inadvertently use CHCs during early pregnancy. Epidemiologic studies and meta-analyses have not found an increased risk of genital or non-genital birth defects (including cardiac anomalies and limb-reduction defects) following exposure to low dose CHCs prior to conception or during early pregnancy.
• The administration of CHCs to induce withdrawal bleeding should not be used as a test for pregnancy. CHCs should not be used during pregnancy to treat threatened or habitual abortion.

Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Etonogestrel and Ethinyl Estradiol Vaginal Ring in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Etonogestrel and Ethinyl Estradiol Vaginal Ring during labor and delivery.

Nursing Mothers

The effects of etonorgestrel and ethinyl estradiol vaginal ring in nursing mothers have not been evaluated and are unknown. When possible, advise the nursing mother to use other forms of contraception until she has completely weaned her child. CHCs can reduce milk production in breastfeeding mothers. This is less likely to occur once breastfeeding is well-established; however, it can occur at any time in some women. Small amounts of contraceptive steroids and/or metabolites are present in breast milk.

Pediatric Use

Safety and efficacy of etonorgestrel and ethinyl estradiol vaginal ring have been established in women of reproductive age. Efficacy is expected to be the same for postpubertal adolescents under the age of 18 and for users 18 years and older. Use of this product before menarche is not indicated.

Geriatic Use

Etonorgestrel and ethinyl estradiol vaginal ringhas not been studied in postmenopausal women and is not indicated in this population.

Gender

There is no FDA guidance on the use of Etonogestrel and Ethinyl Estradiol Vaginal Ring with respect to specific gender populations.

Race

There is no FDA guidance on the use of Etonogestrel and Ethinyl Estradiol Vaginal Ring with respect to specific racial populations.

Renal Impairment

The effect of renal impairment on the pharmacokinetics of etonorgestrel and ethinyl estradiol vaginal ring has not been studied.

Hepatic Impairment

The effect of hepatic impairment on the pharmacokinetics of etonorgestrel and ethinyl estradiol vaginal ring has not been studied. Steroid hormones may be poorly metabolized in patients with impaired liver function. Acute or chronic disturbances of liver function may necessitate the discontinuation of CHC use until markers of liver function return to normal.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Etonogestrel and Ethinyl Estradiol Vaginal Ring in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Etonogestrel and Ethinyl Estradiol Vaginal Ring in patients who are immunocompromised.

Administration and Monitoring

Administration

• Intravaginal

Monitoring

There is limited information regarding Etonogestrel and Ethinyl Estradiol Vaginal Ring Monitoring in the drug label.

IV Compatibility

There is limited information regarding the compatibility of Etonogestrel and Ethinyl Estradiol Vaginal Ring and IV administrations.

Overdosage

There have been no reports of serious ill effects from overdose of CHCs. Overdosage may cause withdrawal bleeding in females and nausea. If the ring breaks, it does not release a higher dose of hormones. In case of suspected overdose, all etonogestrel and ethinyl estradiol vaginal ring rings should be removed and symptomatic treatment given.

Pharmacology

Etonogestrel and Ethinyl Estradiol Vaginal Ring
Systematic (IUPAC) name
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CAS number	?
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PubChem	?
Chemical data
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Pharmacokinetic data
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Therapeutic considerations
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Etonogestrel and Ethinyl Estradiol Vaginal Ring

Combination of
Etonogestrel	Progestogen
Ethinyl estradiol	Estrogen
[[{{{component3}}}]]	? Class
[[{{{component4}}}]]	? Class
[[{{{component5}}}]]	? Class
Clinical data
AHFS/Drugs.com	Micromedex Detailed Consumer Information
MedlinePlus	a604032
Routes of administration	vaginal ring
ATC code	G02BB01 (WHO)
Legal status
Legal status	US: ℞-only
Identifiers
CAS Number	54048-10-1 Y 57-63-6
PubChem CID	9960701
ChemSpider	NA N
E number	{{#property:P628}}
ECHA InfoCard	{{#property:P2566}}
NY (what is this?)  (verify)

Mechanism of Action

Combination hormonal contraceptives act by suppression of gonadotropins.

Structure

NuvaRing (etonogestrel/ethinyl estradiol vaginal ring) is a non-biodegradable, flexible, transparent, colorless to almost colorless, combination contraceptive vaginal ring containing two active components, a progestin, etonogestrel (13-ethyl-17-hydroxy-11-methylene-18,19-dinor-17α-pregn-4-en-20-yn-3-one) and an estrogen, ethinyl estradiol (19-nor-17α-pregna-1,3,5(10)-trien-20-yne-3,17-diol). When placed in the vagina, each ring releases on average 0.120 mg/day of etonogestrel and 0.015 mg/day of ethinyl estradiol over a three-week period of use. NuvaRing is made of ethylene vinylacetate copolymers (28% and 9% vinylacetate) and magnesium stearate and contains 11.7 mg etonogestrel and 2.7 mg ethinyl estradiol. NuvaRing is not made with natural rubber latex. NuvaRing has an outer diameter of 54 mm and a cross-sectional diameter of 4 mm. The molecular weights for etonogestrel and ethinyl estradiol are 324.46 and 296.40, respectively. The structural formulas are as follows:

This image is provided by the National Library of Medicine.

File:Ethinyl Estraiol Structure.png

This image is provided by the National Library of Medicine.

Pharmacodynamics

Although the primary effect of this action is inhibition of ovulation, other alterations include changes in the cervical mucus (which increase the difficulty of sperm entry into the uterus) and the endometrium (which reduce the likelihood of implantation).

Pharmacokinetics

• Absorption:

• Etonogestrel: Etonogestrel released by etonogestrel and ethinyl estradiol vaginal ring is rapidly absorbed. The bioavailability of etonogestrel after vaginal administration is approximately 100%. The serum etonogestrel and ethinyl estradiol concentrations observed during three weeks of NuvaRing use are summarized in the table below.
• Ethinyl estradiol: Ethinyl estradiol released by etonogestrel and ethinyl estradiol vaginal ring is rapidly absorbed. The bioavailability of ethinyl estradiol after vaginal administration is approximately 56%, which is comparable to that with oral administration of ethinyl estradiol. The serum ethinyl estradiol concentrations observed during three weeks of etonogestrel and ethinyl estradiol vaginal ring use are summarized in the table below.

This image is provided by the National Library of Medicine.

• The pharmacokinetic profile of etonogestrel and ethinyl estradiol during use of etonogestrel and ethinyl estradiol vaginal ring is shown in the figure below.

This image is provided by the National Library of Medicine.

• The pharmacokinetic parameters of etonogestrel and ethinyl estradiol were determined during one cycle of etonogestrel and ethinyl estradiol vaginal ring use in 16 healthy female subjects and are summarized in the table below.

This image is provided by the National Library of Medicine.

• Prolonged use of etonogestrel and ethinyl estradiol vaginal ring: The mean serum etonogestrel concentration at the end of the fourth week of continuous use of etonogestrel and ethinyl estradiol vaginal ring was 1272 ± 311 pg/mL compared to a mean concentration range of 1578 ± 408 to 1374 ± 328 pg/mL at the end of weeks one to three. The mean serum ethinyl estradiol concentration at the end of the fourth week of continuous use of etonogestrel and ethinyl estradiol vaginal ring was 16.8 ± 4.6 pg/mL compared to a mean concentration range of 19.1 ± 4.5 to 17.6 ± 4.3 pg/mL at the end of weeks one to three.

• Distribution:

• Etonogestrel: Etonogestrel is approximately 32% bound to sex hormone-binding globulin (SHBG) and approximately 66% bound to albumin in blood.
• Ethinyl estradiol: Ethinyl estradiol is highly but not specifically bound to serum albumin (98.5%) and induces an increase in the serum concentrations of SHBG.

• Metabolism: In vitro data shows that both etonogestrel and ethinyl estradiol are metabolized in liver microsomes by the cytochrome P450 3A4 isoenzyme. Ethinyl estradiol is primarily metabolized by aromatic hydroxylation, but a wide variety of hydroxylated and methylated metabolites are formed. These are present as free metabolites and as sulfate and glucuronide conjugates. The hydroxylated ethinyl estradiol metabolites have weak estrogenic activity. The biological activity of etonogestrel metabolites is unknown.
• Excretion: Etonogestrel and ethinyl estradiol are primarily eliminated in urine, bile and feces.
• Drug Interactions:

• The drug interactions of etonogestrel and ethinyl estradiol vaginal ring were evaluated in several studies.
• A single-dose vaginal administration of an oil-based 1200-mg miconazole nitrate capsule increased the serum concentrations of etonogestrel and ethinyl estradiol by approximately 17% and 16%, respectively. Following multiple doses of 200 mg miconazole nitrate by vaginal suppository or vaginal cream, the mean serum concentrations of etonogestrel and ethinyl estradiol increased by up to 40%.
• A single-dose vaginal administration of 100-mg water-based nonoxynol-9 spermicide gel did not affect the serum concentrations of etonogestrel and ethinyl estradiol.
• The serum concentrations of etonogestrel and ethinyl estradiol were not affected by concomitant administration of oral amoxicillin or doxycycline in standard dosages during 10 days of antibiotic treatment.

• Tampon Use: The use of tampons had no effect on serum concentrations of etonogestrel and ethinyl estradiol during use of etonogestrel and ethinyl estradiol vaginal ring.

Nonclinical Toxicology

In a 24-month carcinogenicity study in rats with subdermal implants releasing 10 and 20 mcg etonogestrel per day, (approximately 0.3 and 0.6 times the systemic steady-state exposure of women using etonogestrel and ethinyl estradiol vaginal ring), no drug-related carcinogenic potential was observed.Etonogestrel was not genotoxic in the in vitro Ames/Salmonella reverse mutation assay, the chromosomal aberration assay in Chinese hamster ovary cells or in the in vivo mouse micronucleus test. Fertility returned in rats after withdrawal from treatment.

Clinical Studies

• In three large one-year clinical trials enrolling 2,834 women aged 18-40 years, in North America, Europe, Brazil, and Chile, the racial distribution was 93% Caucasian, 5.0% Black, 0.8% Asian, and 1.2% Other. Women with BMI ≥ 30 kg/m2 were excluded from these studies.
• Based on pooled data from the three trials, 2,356 women aged < 35 years completed 23,515 evaluable cycles of etonogestrel and ethinyl estradiol vaginal ring use (cycles in which no back-up contraception was used). The pooled pregnancy rate (Pearl Index) was 1.28 (95% CI [0.8, 1.9]) per 100 women-years of etonogestrel and ethinyl estradiol vaginal ring use. In the US study, the Pearl Index was 2.02 (95% CI [1.1, 3.4]) per 100 women-years of etonogestrel and ethinyl estradiol vaginal ring use.

How Supplied

(Description)

Storage

There is limited information regarding Etonogestrel and Ethinyl Estradiol Vaginal Ring Storage in the drug label.

Images

Drug Images

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Patient Counseling Information

(Patient Counseling Information)

Precautions with Alcohol

Alcohol-NuvaRing interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

There is limited information regarding Etonogestrel and Ethinyl Estradiol Vaginal Ring Brand Names in the drug label.

Look-Alike Drug Names

• (Paired Confused Name 1a) — (Paired Confused Name 1b)
• (Paired Confused Name 2a) — (Paired Confused Name 2b)
• (Paired Confused Name 3a) — (Paired Confused Name 3b)

Drug Shortage Status

Drug Shortage

Price

References

The contents of this FDA label are provided by the National Library of Medicine.