Etonogestrel-Ethinyl Estradiol

Medically Reviewed by Dr. Harshi Dhingra, M.D.

Last Reviewed: Jul 23, 2024

Warnings

Etonogestrel - Ethinyl Estradiol (NuvaRing) Risks, Warnings, and Complications

Ethinyl estradiol - etonogestrel can cause serious adverse effects in certain high-risk people. Talk to your doctor about alternative methods of birth control if you are at a high risk of complications from combination hormonal birth control. Some of the potential risks of etonogestrel - ethinyl estradiol are listed below.

Note: There are several health risks associated with the use of third generation oral contraceptives (including etonogestrel and ethinyl estradiol which are present in NuvaRing). These risks include thromboembolism (blood clots), heart attack, and stroke. There is no data to suggest that the risks associated with ethinyl estradiol concentrations observed with the vaginal route of administration (contraceptive ring) are any different from serum ethinyl estradiol concentrations achieved with oral contraceptives taken by mouth.

SMOKING: Smoking cigarettes while on combined oral hormonal contraceptives is associated with elevated cardiovascular disease risk factors, including blood clots, stroke, and heart attack. This risk is especially high in females 35 years of age and older and those who are heavy smokers (15 or more cigarettes per day). You should strongly consider quitting smoking if you are on hormonal contraceptives. Talk to your doctor about other safer birth control methods if you continue to smoke.
CARDIOVASCULAR RISKS: Oral contraceptive use is linked to an elevated risk of thromboembolic and thrombotic disease (blood clots), myocardial infarction (heart attack), and cerebrovascular disease (thrombotic and hemorrhagic strokes). Additional cardiovascular risk factors include age above 40 years, smoking by women over age 35, immobility due to recent surgery, recent childbirth within the past month, high blood pressure, high cholesterol, diabetes, obesity, certain inherited bleeding disorders, and using contraceptives with higher doses of estrogen.
Seek emergency medical care if you develop signs and symptoms of a blood clot (chest pain, difficulty breathing, sudden weakness or numbness, or leg pain). Tell your doctor you are using hormonal birth control before any surgery. You may need to stop using hormonal birth control for a few weeks before and after the surgery to lower your risk of thromboembolic events (blood clots).
TOXIC SHOCK SYNDROME (TSS): Toxic shock syndrome is a serious complication that can occur with the use of tampons and certain barrier contraceptives. It is very rare with the use of a vaginal ring and no causal relationship has been established between NuvaRing and TSS. Nonetheless, you should be aware of the potential risk and seek immediate medical care if you develop a sudden high fever, vomiting, diarrhea, dizziness, skin rash, or muscle pain.
BREAST CANCER AND CERVICAL CANCER: Studies have not shown a consistent relationship between taking combined hormonal contraceptives and breast cancer risk. Similarly, it is unclear if oral contraceptives increase the risk of cervical cancer. It is unclear if a hormonal contraceptive vaginal ring is different from oral contraceptives in this regard.
LIVER PROBLEMS: Oral hormonal contraceptives have been linked to impaired liver function and an increased risk of developing hepatocellular carcinoma (liver cancer). It is unclear if the same risk is present with the use of a vaginal ring.
RETINAL VASCULAR LESIONS: There are reports of blood clots in the eye after use of oral contraceptives. Tell your doctor immediately if you develop loss of vision, double vision, blurred vision, eyelid swelling, or protrusion of the eye.
USE DURING EARLY PREGNANCY: Birth defects are extremely rare in infants born to women who used oral contraceptives unknowingly during early pregnancy. Nonetheless, do not use NuvaRing (etonogestrel - ethinyl estradiol) to induce withdrawal bleeding as a test for pregnancy.
GALLBLADDER DISEASE: Using etonogestrel - ethinyl estradiol may cause or worsen existing gallbladder disease. This risk is higher in women who have a history of worsening gallbladder problems with prior use of combination hormonal contraceptives.
METABOLIC EFFECTS: Combined oral contraceptives like etonogestrel - ethinyl estradiol can raise your blood sugar and cholesterol levels. Although no changes in glucose tolerance or lipid levels have been noted in studies involving NuvaRing, this risk is present in prediabetic and diabetic women or women with high cholesterol. Tell your provider if you have prediabetes, diabetes, or high cholesterol before starting this birth control method. They will order appropriate medical evaluation before prescribing NuvaRing. Keep all your medical and lab appointments. Your doctor may want to monitor blood sugar and cholesterol levels.
ELEVATED BLOOD PRESSURE: Combined oral contraceptives can lead to an increase in blood pressure. Follow your health care professional’s instructions for checking your blood pressure readings at home. Tell your doctor if you notice high blood pressure while using a vaginal ring. If you have uncontrolled hypertension or kidney problems, your doctor may recommend other birth control methods.
HEADACHE: Headache is a common side effect of combined oral contraceptives. Tell your doctor if you develop a new pattern of headaches, for example, headaches that are severe, persistent, or recurrent. You may need to discontinue etonogestrel - ethinyl estradiol.
IRREGULAR BLEEDING: You may have spotting or breakthrough bleeding on combined hormonal contraceptives. Tell your doctor if it is persistent or severe.
ECTOPIC PREGNANCY: Failure of combined hormonal contraceptives can result in both normal and ectopic pregnancy (pregnancy outside the womb). Ectopic pregnancy is a medical emergency. Tell your doctor immediately or seek emergency medical care if you develop low back pain, shoulder tip pain, cramping, or abnormal vaginal bleeding.

Precautions Before Starting Etonogestrel - Ethinyl Estradiol (NuvaRing)

Tell your doctor if you have had allergic reactions to etonogestrel, ethinyl estradiol, any of the active or inactive ingredients in the vaginal ring, other hormonal contraceptives, or any other drugs. Your pharmacy can give you a list of ingredients.

Give your doctor or pharmacist a complete list of your medications, including prescription drugs, over-the-counter medicines, vitamins, supplements, and herbal products, especially St. John’s Wort. This can help avoid possible drug interactions between etonogestrel - ethinyl estradiol and your other medications.

Give your doctor a complete medical history. Etonogestrel - ethinyl estradiol may not be safe for people with certain medical conditions, such as blood clots, cerebrovascular disease, stroke, chest pain, coronary artery disease, heart attack, heart rhythm abnormalities, heart valve problems, high cholesterol, diabetes, high blood pressure, kidney problems, problems with blood vessels, nerves, or eyes, circulation problems, headaches, vision changes, liver disease, liver tumors, jaundice, bleeding disorders, abnormal vaginal bleeding, breast problems (fibrocystic breast disease, breast nodules, abnormal mammogram), personal or family history of breast cancer, other types of cancers, hereditary angioedema, seizures, depression, dark patches on the skin (melasma), prolapsed (dropped) bladder, rectum, or uterus, conditions that make your vagina more prone to irritation, toxic shock syndrome, thyroid disease, or gallbladder disease. Also tell your doctor if you have recently delivered a baby or suffered a miscarriage or abortion.

Tell your doctor if you are pregnant or could be pregnant. You should not use etonogestrel - ethinyl estradiol vaginal ring if you are pregnant. Also, you should not use the vaginal ring if you are nursing an infant with breast milk as it can affect breast milk production.

Precautions During Use of Etonogestrel - Ethinyl Estradiol (NuvaRing)

Keep all your medical and lab appointments while on etonogestrel - ethinyl estradiol. Your doctor may want to perform a physical examination and/or order certain laboratory tests.

In case of a missed menstrual period, if you have not followed the prescribed method of using the vaginal ring (i.e., you left the vaginal ring out for more than 3 hours or had a ring-free interval of more than one week), you should do a pregnancy test after the first missed menstrual period. Discontinue use of the vaginal ring if a pregnancy is confirmed. If you used the vaginal ring as prescribed, do a pregnancy test after two consecutive missed periods. If you retain the vaginal ring for one extra week (a total of four weeks), remove it, allow a ring-free one-week period, and insert a new ring. If you retained the vaginal ring for more than 4 weeks, do a pregnancy test to rule out pregnancy before inserting a new ring.

Tell your health care professionals you are using a contraceptive ring before any surgery, including dental procedures. You may need to temporarily stop using the ring to lower your risk of blood clots before and after certain surgical procedures.

If you note any vision changes or difficulty in wearing contact lenses, see your eye doctor.

Hormonal contraceptive use can lead to dark patches (hyperpigmentation) of the facial skin. Before starting treatment, tell your doctor if you’ve had skin discoloration (melasma) from hormonal contraceptives or during pregnancy in the past. Wear protective clothing and use sunscreen to protect your skin from sunlight.

Talk to your doctor if you develop symptoms of severe depression or mood changes while using etonogestrel - ethinyl estradiol.

Etonogestrel - Ethinyl Estradiol (NuvaRing) Drug Interactions

The use of hormonal contraceptives with certain other medicines can affect how the medications work. Using certain combinations of drugs together can increase the risk of severe adverse effects. Your doctor may change the doses of your medications, switch you to different medications, and/or monitor you carefully for adverse effects if there are known interactions between etonogestrel - ethinyl estradiol and your other medicines.

You should not take the following medications with etonogestrel - ethinyl estradiol:

Combination of ombitasvir, paritaprevir, and ritonavir (Technivie) with or without dasabuvir (in Viekira Pak)

The following medications can also have interactions with etonogestrel - ethinyl estradiol:

Acetaminophen (Tylenol, others)
Medications used to treat fungal infections, such as itraconazole (Onmel, Sporanox), ketoconazole (Nizoral), fluconazole (Diflucan), griseofulvin (Gris-Peg), miconazole (Oravig), and voriconazole (Vfend)
Medications prescribed for nausea and vomiting, such as aprepitant (Emend)
Vitamin C (ascorbic acid)
Cholesterol-lowering drugs such as atorvastatin (Lipitor) and clofibric acid
Medications prescribed for seizure disorders, such as barbiturates, carbamazepine (Tegretol, Teril, others), topiramate (Topamax), lamotrigine (Lamictal), oxcarbazepine (Trileptal), felbamate (Felbatol), phenobarbital, and phenytoin (Dilantin, Phenytek)
Medications for pulmonary arterial hypertension, such as bosentan (Tracleer)
Immunosuppressants such as cyclosporine (Neoral, Sandimmune, Gengraf)
HIV/AIDS medications such as darunavir (Prezista) with ritonavir (Norvir), atazanavir (Reyataz), delavirdine (Rescriptor), etravirine (Intelence), efavirenz (Sustiva), indinavir (Crixivan), nelfinavir (Viracept), lopinavir (Kaletra), nevirapine (Viramune), saquinavir (Invirase), tipranavir (Aptivus), and ritonavir (Norvir)
Pain medications such as morphine (Kadian, Astramorph, others)
Corticosteroids such as prednisolone (Orapred)
Antibiotic treatment for tuberculosis, such as rifabutin (Mycobutin), rifampin (Rifadin, Rimactane), rufinamide (Banzel)
Insomnia medications such as temazepam (Restoril)
Medications used to treat lung conditions, such as theophylline (Elixophyllin, Theo-24, others)
Muscle relaxants such as tizanidine (Zanaflex)
Thyroid hormone

The above list may not include all the possible interactions of etonogestrel - ethinyl estradiol. Give your doctor or pharmacist a complete list of your medications, including prescription drugs, over-the-counter medicines, dietary supplements, and herbal remedies. Also, tell your healthcare provider if you smoke, drink alcohol, or use recreational drugs because some of these substances can cause serious health complications when used with prescription and over-the-counter medicines.

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