The vaginal ring is a form of birth control that's been available in the U.S. since 2001. The ring is inserted into the vagina and is designed to gradually release hormones for three weeks out of each month to prevent pregnancy. Two prescription contraceptive rings are available in the U.S.: NuvaRing and Annovera.
How Does the Vaginal Ring Work?
Both NuvaRing and Annovera are made of a combination of two female sex hormones: an estrogen called ethinyl estradiol and a progestin:
- NuvaRing releases a slightly higher amount of ethinyl estradiol each day. It also contains the progestin etonogestrel.
- Annovera contains the progestin segesterone acetate.
When inserted, the ring should stay in the vagina for three continuous weeks. After that, it is removed for one week. Most women experience withdrawal bleeding during this ring-free week.
An important distinction to be aware of is that if you use NuvaRing, you must discard the ring and insert a new one after seven days. If you use Annovera, you'll use the same ring for an entire year. Follow the package directions for washing the ring after it's removed and again before you reinsert it after the seven days off.
The primary way the vaginal ring works to prevent pregnancy is by preventing ovulation (when the ovary releases an egg).
If ovulation does occur, the hormones in a vaginal ring make it harder for sperm to enter the uterus and reach the egg. If the sperm does reach the egg, these hormones also make it less likely for the fertilized egg to implant in the endometrium (uterus lining).
Benefits of Using the Vaginal Ring
There are many advantages to using a vaginal ring. Some of these include:
- Convenience. One NuvaRing provides one month of contraception, while an Annovera ring provides an entire year.
- Less frequent maintenance compared to pills. You won't have to refill your Annovera prescription for a year.
- Bypasses digestive system. This means that the hormones in the vaginal ring aren't broken down by the liver like the hormones in birth control pills are. Bypassing the digestive tract also allows for consistent hormone release and better menstrual cycle control.
- Reduced risk of human error. You won't have to remember a daily pill, but do make sure you know how to use and replace your ring correctly—and what to do if it falls out.
- Lower dosage needed. The vaginal ring contains half the estrogen dose birth control pills do.
- Noninvasive and discreet.
Potential Side Effects and Risks
If you decide to use a vaginal ring to prevent pregnancy, keep in mind that there are risks and side effects associated with this medicine. Many of these are similar to the risks associated with other forms of hormonal birth control.
Common Side Effects
Common side effects of a vaginal ring include the following:
- Headache
- Nausea
- Vomiting
- Diarrhea
- Vaginal yeast infection
- Stomach pain
- Pain during periods
- Vaginal discharge
- Urinary tract infection (UTI)
- Breast pain
- Irregular bleeding, including heavy periods, spotting (bleeding between periods), or a lack of periods
- Vaginal itching
- Vaginal discomfort
- Weight gain
- Acne
- Decreased sex drive
Let your healthcare provider know if you experience these or any other side effects that interfere with your daily life. Many different birth control options are available, so if the vaginal ring doesn't work for your lifestyle, another medication may.
Serious Side Effects
Serious side effects include:
- Blood clots
- High blood pressure
- Stroke risk
- Mood changes, including depression, anxiety, and mood swings
- Hypersensitivity reactions
- Toxic shock syndrome (TSS)
- Spontaneous abortion
Monitor yourself for signs of blood clots, which can include:
- Fast heart rate
- Chest pain
- Shortness of breath
- Redness, pain, or swelling of the legs
Signs of a stroke include weakness and difficulty speaking. Call 911 or head to your nearest hospital promptly if you experience serious symptoms like dizziness, fever, or a rash. These can be signs of a serious reaction.
Compared to hormonal contraceptive pills, the vaginal ring is associated with a lower risk of side effects overall. Keep in mind, though, that the ring is more likely to cause vaginal discharge or irritation. This makes sense because the vagina is the site of application.
How to Use the Vaginal Ring Correctly
How to Insert a Vaginal Ring
If your healthcare provider prescribes a vaginal ring, make sure you're clear on when to insert It for the first time. This can vary depending on individual factors, like whether you are switching from another birth control medication or whether you've recently given birth or had a miscarriage or abortion.
To insert the ring, follow these steps:
- Choose a comfortable position: The manufacturer suggests standing with one leg up, squatting, or lying down.
- Squeeze the sides of the ring together and insert it into the vagina.
- Note the date and time you inserted the ring so that you can remove it 21 days later at about the same time of day.
In general, NuvaRing should start on the same day you start your period (day 1 of your cycle).
You can start Annovera on days 2 through 5 of your menstrual period without needing backup birth control if you have regular cycles. If you have irregular periods or choose to insert Annovera at any other point during your monthly cycle, you'll need to use a backup birth control method for the first week the ring is in place.
How Long Should I Leave It In?
A vaginal ring can remain in the vagina during menstruation (a period). You can use tampons while the ring is in place. They won't affect the medicine, but be careful that the ring doesn't accidentally come out when you are removing a tampon.
Remove the ring 21 days (three weeks) after inserting it. To remove it, hook the front of the ring with your index finger and gently pull it out of the vagina.
For replacement:
- You should replace a NuvaRing exactly one week after you remove the old one, regardless of whether or not you're bleeding.
- Wash the Annovera ring after you remove it and again seven days later when you reinsert it. You don't replace the Annovera ring itself for a year.
What Do I Do If My Vaginal Ring Falls Out?
Having a plan for what to do if the ring falls out is essential. This can happen during sexual intercourse, while changing a tampon, or even during a bowel movement. If your ring falls out:
- NuvaRing: Rinse in cool or lukewarm water and replace it within three hours to maintain effectiveness.
- Annovera: Rinse with soap and warm water and replace it in the vagina within two hours.
If your NuvaRing is out for more than three hours in a row:
- During the first two weeks it's in place: Reinsert the ring and use backup contraception (like a condom) for the next seven days.
- During the third week (the last week it's in the vagina): Throw the ring away. You can either insert a new ring for three weeks or wait up to seven days and then insert a new one. In either case, you'll need backup birth control, such as a condom, for the first seven days that you use the new ring.
The protocol to follow if Annovera accidentally falls out is slightly different. If your Annovera ring is out for more than two hours (either in a row or total in a 21-day period), use backup birth control, such as a condom, for the next seven days.
Who Should Consider Using the Vaginal Ring?
The vaginal ring is a good option for the following populations:
- Women who prefer monthly contraception
- Those who don't like taking pills or are unable to swallow them
- Annovera is ideal for females who can't make monthly or quarterly trips to the pharmacy, such as international travelers or those who don't have regular transportation
Some populations should not use the vaginal ring due to risks of serious side effects. These include:
- Women over age 35 who smoke cigarettes
- Women who face a high risk of blood clots
- Those with a history of breast cancer or other estrogen- or progestin-sensitive cancers
- Those with liver disease
- Women who are pregnant
- Those with undiagnosed abnormal uterine bleeding
- Those allergic to any ingredients of the vaginal ring
- Those taking certain medications for hepatitis C
- Women who are breastfeeding
Of note, the Annovera manufacturer did not study it in females with a body mass index (BMI) over 29, so there's less safety data for this population. Annovera may be less effective in this group.
Effectiveness of the Vaginal Ring
The vaginal ring is about as effective as birth control pills and hormonal patches. One to three women out of 100 become pregnant in the first year of using NuvaRing. Two to four women out of 100 become pregnant within the first year of using Annovera.
To put this in perspective, the vaginal ring is less effective than birth control methods like implants and intrauterine devices (IUDs). But it is more effective than condoms, diaphragms, or the withdrawal method.
Some factors may reduce the effectiveness of a vaginal ring:
- Using it incorrectly. For instance, having NuvaRing out of the vagina for more than three hours at a time or having Annovera out of the vagina for two hours or more keeps these products from working optimally. Additionally, not inserting your vaginal ring at the right time can keep it from working optimally.
- Taking certain medications or supplements, including some seizure medicines and the herbal supplement St. John's wort. These can lower the levels of hormones in vaginal rings and can also make them less effective.
As discussed above, if you use your ring incorrectly or at the wrong time, contact your healthcare provider or pharmacist as soon as possible or consult the package insert.
Other Considerations
If you are considering using a vaginal ring to prevent pregnancy, keep in mind the following.
- Cost. The vaginal ring costs more than other contraceptives.
- Insurance coverage. Check with your insurance company to see if they cover a vaginal ring, and if so, which one they prefer.
- Any psychological considerations. Using a vaginal ring for birth control affects women in different ways. Some report improved sexual function, while others find it uncomfortable during sex.
- Environmental impact. You should not flush the vaginal ring down the toilet. NuvaRing should be wrapped in its original package and thrown away. Annovera should be stored in the case that comes with it between cycles. At the end of 12 months, discard the ring in the trash or through a drug take-back program.
Summary
The vaginal ring is a hormonal birth control that is inserted into the vagina for three weeks at a time.
NuvaRing and Annovera are the two vaginal rings marketed in the U.S. They work about as well as birth control pills and hormonal patches to prevent pregnancy.
If you use a vaginal ring, make sure you carefully follow directions for how and when to insert it and remove it and what to do if it accidentally falls out.
Stay alert for signs of serious side effects while using a vaginal ring. These can include blood clots, mood changes, and high blood pressure.
