Drug Description
NuvaRing contains 11.7 mg etonogestrel and 2.7 mg ethinylestradiol. The ring releases etonogestrel and ethinylestradiol at an average amount of 0.120 mg and 0.015 mg, respectively per 24 hours, over a period of 3 weeks.

Presentation
Vaginal delivery system.NuvaRing is flexible, transparent, and colourless to almost colourless ring, with an outer diameter of 54 mm and a cross-sectional diameter of 4 mm.

Indications
Contraception. NuvaRing is intended for women of fertile age. The safety and efficacy has been established in women aged 18 to 40 years.

Adult Dosage
The woman herself can insert NuvaRing in the vagina. The physician should advise the woman how to insert and remove NuvaRing. For insertion the woman should choose a position that is most comfortable for her, e.g. standing with one leg up, squatting, or lying down. NuvaRing should be compressed and inserted into the vagina until it feels comfortable. The exact position of NuvaRing in the vagina is not critical for the contraceptive effect of the ring.Once NuvaRing has been insertedit is left in the vagina continuously for 3 weeks. It is good habit for the woman to regularly verify the presence of NuvaRing.NuvaRing must be removed after 3 weeks of use on the same day of the week as the ring was inserted. After a ring-free interval of one week a new ring is inserted (e.g. when NuvaRing is inserted on a Wednesday at about 22.00 h the ring should be removed again on the Wednesday 3 weeks later at about 22.00 h. The following Wednesday a new ring should be inserted). NuvaRing can be removed by hooking the index finger under the ring or by grasping the ring between the index and middle finger and pulling it out. The used ring should be placed in the sachet (keep out of the reach of children and pets) and discarded. The withdrawal bleed usually starts 2-3 days after removal of NuvaRing and may not have finished completely before the next ring insertion is due.Howtostart NuvaringNo hormonal contraceptive use in the preceding cycleNuvaRing has to be inserted on the first day of the woman's natural cycle (i.e.the first day of her menstrual bleeding). Starting on days 2-5 is allowed, but during the first cycle a barrier method is recommended in addition for the first 7 days of NuvaRing use.Changing from a combined hormonal contraceptiveThe woman should insert NuvaRing at the latest on the day following the usual tablet-free, patch-free or placebo tablet interval of her previous combined hormonal contraceptive.If the woman has been using her previous method consistently and correctly and if it is reasonably certain that she is not pregnant she may also switch from her previous combined hormonal contraceptive on any day of the cycle.The hormone-free interval of the previous method should never be extended beyond its recommended length.Changing from a progestagen-only method (minipill, implant, or injection), or from a progestagen-releasing intrauterine system [IUS].The woman may switch on any day from the minipill (from an implant, or the IUS on the day of its removal, from an injectable when the next injection would be due) but should in all of these cases use an additional barrier method for the first 7 days of NuvaRing use.Following first-trimester abortionThe woman may start immediately. When doing so, she needs not to take additional contraceptive measures. If an immediate switch is considered undesirable, the woman should follow the advice given for 'no hormonal contraceptive use in the preceding cycle'. In the mean-time, she should be advised to use an alternative contraceptive method.Following delivery or second-trimester abortionWomen should be advised to start during the fourth week after delivery or second-trimester abortion. When starting later, the woman should be advised to additionally use a barrier method for the first 7 days of NuvaRing use. However, if intercourse has already occurred, pregnancy should be excluded or the woman has to wait for her first menstrual period, before starting NuvaRing use.DEVIATIONS FROM THE RECOMMENDED REGIMENContraceptive efficacy and cycle control may be compromised if the woman deviates from the recommended regimen. To avoid loss of contraceptive efficacy in case of a deviation, the following advice can be given:What to do in case of a lengthened ring-free intervalThe woman should insert a new ring as soon as she remembers. A barrier method such as a condom should be used in addition for the next 7 days. If intercourse took place during the ring-free interval, the possibility of a pregnancy should be considered. The longer the ring-free interval, the higher the risk of a pregnancy.What to do if the ring was temporarily outside the vaginaNuvaRing should be left in the vagina for a continuous period of 3 weeks. If the ring is accidentally expelled, it can be rinsed with cool to lukewarm (not hot) water and should be reinserted immediately.If NuvaRing has been out of the vagina for less than 3 hours contraceptive efficacy is not reduced. The woman should reinsert the ring as soon as possible, but at the latest within 3 hours.If NuvaRing has been out of the vagina, or is suspected to have been out of the vagina for more than 3 hours during the 1st or 2nd week of use, contraceptive efficacy may be reduced. The woman should reinsert the ring as soon as she remembers. A barrier method such as a condom should be used until NuvaRing has been in the vagina continuously for 7 days. The longer the time NuvaRing has been out of the vagina and the closer this is to the ring-free interval, the higher the risk of a pregnancy.If NuvaRing has been out of the vagina, or is suspected to have been out of the vagina for more than 3 hours during the 3rd week of the three-week use period, contraceptive efficacy may be reduced. The woman should discard that ring, and one of the following two options should be chosen:1 Insert a new ring immediatelyNote: 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 Have a withdrawal bleeding and insert a new ring no later than 7 days (7x24 hours) from the time the previous ring was removed or expelled. Note: This option should only be chosen if the ring was used continuously for the preceding 7 days.What to do in case of lengthened ring-useAlthough this is not the recommended regimen, as long as NuvaRing has been used for maximally 4 weeks, contraceptive efficacy is still adequate. The woman may maintain her one-week ring-free interval and subsequently insert a new ring. If NuvaRing has been left in place for more than 4 weeks, contraceptive efficacy may be reduced and pregnancy should be ruled out before inserting a new NuvaRing.If the woman has not adhered to the recommended regimen and subsequently has no withdrawal bleed in the following ring-free interval, pregnancy should be ruled out before inserting a new NuvaRing.Howtoshiftperiodsorhow todelayaperiodIf in exceptional cases a period needs to be delayed, the woman may insert a new ring without having a ring-free interval. The next ring can be used for up to 3 weeks again. The woman may experience bleeding or spotting. Regular use of NuvaRing is then resumed after the usual one week ring-free interval.To shift her period to another day of the week than the woman is used to with her current scheme, she can be advised to shorten her forthcoming ring-free interval by as many days as she likes. The shorter the ring-free interval, the higher the risk that she does not have a withdrawal bleed and will experience breakthrough bleeding and spotting during the use of the next ring.

Contra Indications
NuvaRing should not be used in the presence of any of the conditions listed below. Should any of the conditions appear for the first time during the use of NuvaRing, it should be removed immediately.Presence or history of venous thrombosis, with or without the involvement of pulmonary embolism.Presence or history of arterial thrombosis (e.g. cerebrovascular accident, myocardial infarction) or prodromi of a thrombosis (e.g. angina pectoris or transient ischaemic attack).Known predisposition for venous or arterial thrombosis, with or without hereditary involvement such as Activated Protein C (APC) resistance, antithrombin-III deficiency, protein C deficiency, protein S deficiency, hyperhomocysteinaemia and antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant).History of migraine with focal neurological symptoms.Diabetes mellitus with vascular involvement.The presence of a severe or multiple risk factor(s) for venous or arterial thrombosis may also constitute a contraindication (see under 'Special warnings and precautions for use').Pancreatitis or a history thereof if associated with severe hypertriglyceridemia.Presence or history of severe hepatic disease as long as liver function values have not returned to normal.Presence or history of liver tumours (benign or malignant).Known or suspected malignant conditions of the genital organs or the breasts, if sex steroid-influenced.Undiagnosed vaginal bleeding.Hypersensitivity to the active substances or to any of the excipients of NuvaRing

Special Precautions
If any of the conditions/risk factors mentioned below is present, the benefits of the use of NuvaRing should be weighed against the possible risks for each individual woman and discussed with the woman before she decides to start using it. In the event of aggravation, exacerbation or first appearance of any of these conditions or risk factors, the woman should contact her physician. The physician should then decide on whether its use should be discontinued. All data presented below are based upon epidemiological data obtained with combined oral contraceptives (COC). No epidemiological data are available on vaginal route of administration for the hormones but the warnings are also considered applicable to the use of NuvaRing.1. Circulatory DisordersThe use of hormonal contraceptives has been associated with the occurrence of venous thrombosis (deep venous thrombosis and pulmonary embolism) and arterial thrombosis and associated complications, sometimes with fatal consequences.Use of any combined oral contraceptive (COC) carries an increased risk of venous thromboembolism (VTE) compared with no use. This increased risk is less than the risk of VTE associated with pregnancy, which is estimated as 60 per 100 000 pregnant woman years. VTE is fatal in 1%-2% of cases.It is not known how NuvaRing influences the risk compared with other combined hormonal contraceptives.Extremely rarely, thrombosis has been reported to occur in other blood vessels, e.g. hepatic, mesenteric, renal, cerebral, or retinal veins and arteries, in COC users. There is no consensus as to whether the occurrence of these events is associated with the use of COCs.Symptoms of venous or arterial thrombosis can include: unusual, unilateral leg pain and / or swelling; sudden severe pain in the chest, whether or not it radiates to the left arm; sudden breathlessness; sudden onset of coughing; any unusual, severe, prolonged headache; sudden partial or complete loss of vision; diplopia; slurred speech or aphasia; vertigo; collapse with or without focal seizure; weakness or very marked numbness suddenly affecting one side or one part of the body; motor disturbances; 'acute' abdomen.The risk of venous thromboembolism (VTE) increases with:increasing agea positive family history (i.e. venous thromboembolism ever in a sibling or parent at a relatively early age). If a hereditary predisposition is suspected, the woman should be referred to a specialist for advice before deciding about any hormonal contraceptive useprolonged immobilization, major surgery, any surgery to the legs, or major trauma. In these situations it is advisable to discontinue use (in the case of elective surgery at least four weeks in advance) and not to resume until two weeks after complete remobilizationobesity (body mass index over 30 kg/m2)and possibly also with superficial thrombophlebitis and varicose veins.There is no consensus about the possible role of these conditions in the etiology of venous thrombosis.The risk of arterial thromboembolic complications increases with:increasing agesmoking (with heavier smoking and increasing age the risk further increases, especially in women over 35 years of age)dyslipoproteinemiaobesity (body mass index over 30 kg/m2)hypertensionmigraineva lvular heart diseaseatrial fibrillationa positive family history (arterial thrombosis ever in a sibling or parent at a relatively early age). If a hereditary predisposition is suspected, the woman should be referred to a specialist for advice before deciding about any hormonal contraceptive use.Biochemical factors that may be indicative of hereditary or acquired predisposition for venous or arterial thrombosis include Activated Protein C (APC) resistance, hyperhomocysteinaemia, antithrombin-III deficiency, protein C deficiency, protein S deficiency, antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant).Other medical conditions, which have been associated with adverse circulatory events, include diabetes mellitus, systemic lupus erythematosus, hemolytic uraemic syndrome, chronic inflammatory bowel disease (e.g. Crohn's disease or ulcerative colitis).The increased risk of thromboembolism in the puerperium must be considered.Increase in frequency or severity of migraine (which may be prodromal of a cerebrovascular event) may be a reason for immediate discontinuation of NuvaRing use.Women using COCs should be specifically pointed out to contact their physician in case of possible symptoms of thrombosis. In case of suspected or confirmed thrombosis, COC use should be discontinued. Adequate contraception should be initiated because of the teratogenicity of anti-coagulant therapy (coumarins).2. TumoursSome epidemiological studies indicate that the long-term use of oral contraceptives displays a risk factor for the development of cervical cancer in women infected with human papillomavirus (HPV). However, there is still controversy about the extent to which this finding is influenced by confounding effects (e.g. differences in number of sexual partners or in use of barrier contraceptives). No epidemiological data on the risk of cervical cancer in users of NuvaRing are available (see 'medical examination/consultation').A meta-analysis from 54 epidemiological studies reported that there is a slightly increased relative risk (RR = 1.24) of having breast cancer diagnosed in women who are currently using COCs. The excess risk gradually disappears during the course of the 10 years after cessation of COC use. Because breast cancer is rare in women under 40 years of age, the excess number of breast cancer diagnoses in current and recent COC users is small in relation to the overall risk of breast cancer. The breast cancers diagnosed in ever-users tend to be less advanced clinically than the cancers diagnosed in never-users. The observed pattern of increased risk may be due to an earlier diagnosis of breast cancer in COC users, the biological effects of COCs or a combination of both.In rare cases, benign liver tumours, and even more rarely, malignant liver tumours have been reported in users of COCs. In isolated cases, these tumours have led to life-threatening intra-abdominal hemorrhages. Therefore, a hepatic tumour should be considered in the differential diagnosis when severe upper abdominal pain, liver enlargement or signs of intra-abdominal hemorrhage occur in women using NuvaRing.3. Other conditionsWomen with hypertriglyceridemia, or a family history thereof, may be at an increased risk of pancreatitis when using hormonal contraceptives.Although small increases in blood pressure have been reported in many women using hormonal contraceptives, clinically relevant increases are rare. A definitive relationship between hormonal contraceptive use and clinical hypertension has not been established. However, if a sustained clinically significant hypertension develops during the use of NuvaRing then it is prudent for the physician to suspend the use of the ring and treat the hypertension. Where considered appropriate, NuvaRing use may be resumed if normotensive values can be achieved with antihypertensive therapy.The following conditions have been reported to occur or deteriorate with both pregnancy and during the use of hormonal contraceptives, but the evidence of an association with its use is inconclusive: jaundice and / or pruritus related to cholestasis; gallstone formation; porphyria; systemic lupus erythematosus; hemolytic uraemic syndrome; Sydenham's chorea; herpes gestationis; otosclerosis-related hearing loss, (hereditary) angioedema.Acute or chronic disturbances of liver function may necessitate the discontinuation of the use of NuvaRing until markers of liver function return to normal. Recurrence of cholestatic jaundice and/ or pruritus related to cholestasis, which occurred first during pregnancy or previous use of sex steroids necessitates the discontinuation of the ring.Although estrogens and progestagens may have an effect on peripheral insulin resistance and glucose tolerance, there is no evidence for a need to alter the therapeutic regimen in diabetics using hormonal contraception. However, diabetic women should be carefully monitored while using NuvaRing especially in the first months of use.A deterioration of Crohn's disease and colitis ulcerosa has been reported in association with the use of hormonal contraceptives.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 whilst using NuvaRing.If a woman has any of the following conditions she may not be able to insert NuvaRing correctly or may in fact lose the ring: prolapse of the uterine cervix, cystocele and or rectocele, severe or chronic constipation.Very rarely it has been reported that NuvaRing is inadvertently inserted in the urethra and possibly ending up in the bladder. Therefore, incorrect positioning should be considered in the differential diagnosis in the case of symptoms of cystitis.During the use of NuvaRing, women may occasionally experience vaginitis. There are no indications that the efficacy of NuvaRing is affected by the treatment of vaginitis, nor that the use of NuvaRing affects the treatment of vaginitis.Medical examination/consultationPrior to the initiation or reinstitution of NuvaRing use a complete medical history (including a family medical history) should be taken and pregnancy should be excluded. The blood pressure and a physical examination should be taken, guided by the contraindications and warnings. The woman should be advised to carefully read the package leaflet and to follow the advice given. The frequency and nature of further periodic checks should be based upon established clinical practice and adapted to the individual woman.Women should be advised that NuvaRing does not protect against HIV infections (AIDS) and other sexually transmitted diseases.Reduced efficacyThe efficacy of NuvaRing may be reduced in the event of non-compliance, or concomitant medication.Reducedcycle controlIrregular bleeding (spotting or breakthrough bleeding) may occur during the use of NuvaRing. If bleeding irregularities occur after previously regular cycles while NuvaRing has been used according to the recommended regimen, then non-hormonal causes should be considered, and adequate diagnostic measures are indicated to exclude malignancy or pregnancy. These may include curettage.In some women a withdrawal bleed may not occur during the ring-free interval. If NuvaRing has been used according to the instructions it is unlikely that the woman is pregnant. However, if NuvaRing has not been used according to these instructions prior to the first missed withdrawal bleed or if two withdrawal bleeds are missed, pregnancy must be ruled out before use of NuvaRing is continued.Maleexposure to ethinyl estradioland etonogestrelThe extent and possible pharmacological role of exposure of male sexual partners to ethinylestradiol and etonogestrel through absorption through the penis have not been examined.Broken ringsOn very rare occasions NuvaRing has been reported to get disconnected during use. The woman is advised to remove the broken ring and reinsert a new ring as soon as possible and use a barrier method such as a condom in addition for the next 7 days. The possibility of a pregnancy should be considered and the woman should contact her physician.ExpulsionNuvaRing has been reported to get expelled, for example if the ring has not been inserted properly, while removing a tampon, during sexual intercourse, or in case of severe or chronic constipation. Prolonged expulsion may lead to contraceptive failure and/or breakthrough bleeding. Therefore, to ensure efficacy the woman should be advised to regularly verify the presence of NuvaRing.If NuvaRing is accidentally expelled and is left outside of the vagina for less than 3 hours contraceptive efficacy is not reduced. The woman should rinse the ring with cool to lukewarm (not hot) water and reinsert it as soon as possible, but at the latest within 3 hours.If NuvaRing has been out of the vagina, or is suspected to have been out of the vagina for more than 3 hours contraceptive efficacy may be reduced.

Interactions
Interactions between hormonal contraceptives and other medicinal products may lead to breakthrough bleeding and/or contraceptive failure. The following interactions have been reported in the literature.Hepatic metabolism: Interactions can occur with medicinal products that induce microsomal enzymes, which can result in increased clearance of sex hormones (e.g., phenytoin, phenobarbital, primidone, carbamazepine, rifampicin, and possibly also oxcarbazepine, topiramate, felbamate, ritonavir, griseofulvin and products containing St. John's wort).Women on treatment with any of these medicinal products should temporarily use a barrier method in addition to NuvaRing or choose another method of contraception. With hepatic microsomal enzyme-inducing drugs, the barrier method should be used during the time of concomitant drug administration and for 28 days after their discontinuation.If concomitant drug administration runs beyond the 3 weeks of a ring-cycle, the next ring should be inserted immediately, without having the usual ring-free interval.Contraceptive failures have also been reported with antibiotics, such as penicillins and tetracyclines. The mechanism of this effect has not been elucidated. In a pharmacokinetic interaction study, oral administration of amoxicillin (875 mg, two times daily) or doxycycline (200 mg on day 1, followed by 100mg per day) for 10 days during use of NuvaRing, did not significantly affect pharmacokinetics of etonogestrel and EE. Women on treatment with antibiotics (except amoxicillin and doxycycline) should use the barrier method until 7 days after discontinuation. If concomitant drug administration runs beyond the 3 weeks of a ring-cycle, the next ring should be inserted immediately, without having the usual ring-free interval.Based on pharmacokinetic data, vaginally administered antimycotics and spermicides are unlikely to affect the contraceptive efficacy and safety of NuvaRing. During concomitant use of antimycotic ovules the chance of ring disconnection may be slightly higher.Hormonal contraceptives may interfere with the metabolism of other drugs. Accordingly, plasma and tissue concentrations may either increase (e.g. ciclosporin) or decrease (e.g. lamotrigine).The prescribing information of concomitant medications should be consulted to identify potential interactions.Laboratory TestsThe use of contraceptive steroids may influence the results of certain laboratory tests, including biochemical parameters of liver, thyroid, adrenal and renal function, plasma levels of carrier proteins, (e.g. corticosteroid binding globulin and sex hormone binding globulin), lipid / lipoprotein fractions, parameters of carbohydrate metabolism and parameters of coagulation and fibrinolysis. Changes generally remain within the normal laboratory range.InteractionwithtamponsPharmacokinetic data show that the use of tampons has no effect on the systemic absorption of the hormones released by NuvaRing. On rare occasions NuvaRing might be expelled while removing a tampon (see advice for 'What to do if the ring was temporarily outside the vagina').

Adverse Reactions
The most frequently reported undesirable effects in the clinical trials with NuvaRing were headache and vaginal infections and vaginal discharge, each reported by 5-6% of the women.Adverse drug reactions that have been reported in clinical trials with NuvaRing are listed in the Table below. The most appropriate MedDRA term (version 9.1) to describe a certain adverse event is listed.System Organ ClassCommon 1/100 to 1/10Uncommon 1/1000 to 1/100Post Marketing1Infections and infestationsVaginal infectionCervicitis, Cystitis, Urinary tract infectionImmune system disordersHypersensitivityMetabolism and nutrition disordersIncreased appetitePsychiatric disordersNervous system disordersHeadache, MigraineDizziness, HypoaesthesiaEye disordersVisual disturbanceVascular disordersHot flushGastrointestinal disordersAbdominal pain, NauseaAbdominal distension, Diarrhoea, Vomiting, ConstipationSkin and subcutaneous tissue disordersAcneAlopecia, Eczema, Pruritus, RashUrticariaMusculoskeletal and connective tissue disordersBack pain, Muscle spasms, Pain in extremityRenal and urinary disordersDysuria, Micturition urgency, PollakiuriaReproductive system and breast disordersBreast tenderness, Genital pruritus female, Dysmenorrhoea, Pelvic pain, Vaginal dischargeAmenorrhoea, Breast discomfort, Breast enlargement, Breast mass, Cervical polyp, Coital bleeding, Dyspareunia, Ectropion of cervix, Fibrocystic breast disease, Genital discharge, Menorrhagia, Metrorrhagia, Pelvic discomfort, Premenstrual syndrome, Uterine spasm, Vaginal burning sensation, Vaginal odour, Vaginal pain, Vulvovaginal discomfort, Vulvovaginal drynessGeneral disorders and administration site conditionsFatigue, Irritability, Malaise, Oedema, Sensation of foreign bodyInvestigationsWeight increasedBlood pressure increasedInjury, poisoning and procedural complicationsMedical device discomfort, Vaginal contraceptive device expelledContraceptive device complication, Device breakage1 Listing of adverse events based on spontaneous reporting. It is not possible to determine the exact frequencyIn rare cases partners of women using NuvaRing have reported penis disorders in post marketing surveillance.A number of undesirable effects have been reported in women using combined oral contraceptives, These include:Venous thromboembolic disordersArterial thromboembolic disordersHypertensionHormone-dependent tumours (e.g. liver tumours, breast cancer)Chloasma.

Owner
Organon Laboratories Ltd

Drug Availability
POM

Updated
29 June 2009