NuvaRing: what it is used for, dosage and side effects
NuvaRing is a combined hormonal vaginal ring with two active substances: etonogestrel and ethinylestradiol. It is placed in the vagina and releases both hormones steadily, so there is nothing to take by mouth every day. It is prescription only, because it carries the same class of risk as other combined hormonal contraception and a doctor has to weigh up blood pressure, the risk of blood clots and everything else you take. This page explains how it works, what a doctor checks, and what we can and cannot do about a prescription.
What NuvaRing is and which active substances it contains
NuvaRing is a flexible ring that releases two active substances: etonogestrel, a progestogen, and ethinylestradiol, an oestrogen. Because it contains both, it belongs to the combined hormonal contraceptives, in the same class of risk as the combined pill and the patch.
In the European Medicines Agency data for the Maltese market it is listed with the active substances ethinylestradiol and etonogestrel and the route of administration: vaginal. The route is the difference that patients notice: the hormones are absorbed through the vaginal wall, so there is no daily tablet and no reliance on remembering one.
The form changes the routine, not the class. Everything that applies to combined contraception in terms of the risk of clots and the situations in which it is unsuitable applies here too. The combined pill is described on /medicines/yasmin/ and the patch on /medicines/evra/, with an overview of the group in /contraceptive-pill/.
The exact composition, the release rate and the storage rules are in the patient information leaflet in your pack. The list of medicines authorised in Malta is kept by the Medicines Authority.
What it is used for
The authorised use is contraception in women who choose a combined hormonal method in this form. Used as directed it is a reliable method, but no method is absolutely certain, and reliability in practice depends on using it as the leaflet says.
The form suits people for whom a daily tablet is the weak point of the method, and it avoids the effect of a stomach upset on absorption. It does not suit everyone: it has to be comfortable to place and to remove, and some conditions of the vagina or cervix make it unsuitable.
It does not protect against sexually transmitted infections. Only barrier methods do that, and they can be used alongside it.
It is not emergency contraception and does not replace it. If a risk has already occurred, the route is different and the timing of what you do matters.
How it works and how one ring is used
The two substances act together as in other combined methods: they suppress the release of an egg, change the mucus at the entrance to the womb and change the lining of the womb. Suppressing ovulation is the main mechanism.
One ring covers one cycle. It stays in place for a set number of weeks and is then removed for a break, after which a new ring is used. The exact intervals for your pack are in the patient information leaflet and in the instruction from the doctor who prescribed it, and we do not restate them here, because they belong to the pack you hold.
The ring does not have to sit in an exact position to work. It is placed so that it is comfortable; if you can feel it, it usually helps to push it a little further in. It is not a barrier and it does not sit over the cervix like a cap.
Bleeding during the break is a withdrawal bleed caused by the fall in hormone levels, not a natural period. Its absence does not automatically mean pregnancy, but it is a reason to check, especially if the ring was out for longer than the leaflet allows.
If the ring slips out or is left out too long
A ring can slip out, most often during a bowel movement, when removing a tampon or during sex. That is not unusual and the leaflet for your pack sets out what to do. The one thing that matters is how long it has been out and where in the cycle that happened.
A short interruption is usually dealt with by rinsing the ring in cool or lukewarm water and putting it back, while a longer one can mean that protection has been reduced and that additional protection is needed. Read that section of the leaflet before it happens, because the answer depends on the interval and you will not want to be working it out under pressure.
Do not use hot water on a ring you intend to reuse, and do not use a ring that has been damaged. If you are unsure how long it was out, treat the situation as the less favourable case and use additional protection until you can check with a doctor or a pharmacist.
If a risk of pregnancy has occurred, consider whether emergency contraception is needed, and remember that the sooner that decision is made the better. A doctor or pharmacist can advise on the options.
The risk of blood clots and what the doctor assesses
Combined hormonal contraception raises the risk of venous thromboembolism, that is a clot in a vein which can travel to the lungs. In absolute terms the risk is small in healthy young women, but it is real and it is the reason this method is prescription only, whatever form it comes in.
The risk is higher in the first months after starting or restarting, after a long period without hormonal contraception, in smokers, with rising age, with obesity, after childbirth, after major surgery or long immobility, and where there is a personal or family history of clots or a known clotting disorder. Migraine with aura, uncontrolled high blood pressure and some diseases of the liver, heart or blood vessels make combined contraception unsuitable, not merely something to be careful about.
That is what a doctor weighs up before prescribing, together with blood pressure, and it is why a recent blood pressure reading is a reasonable thing to have to hand. Where combined contraception is not suitable, a progestogen only method may be, and that is a conversation with a doctor.
The warning signs are worth knowing: swelling, pain or heat in one calf; sudden breathlessness or chest pain; coughing up blood; sudden severe headache with disturbed vision or speech, weakness or numbness on one side. Seek urgent medical help, and in an emergency in Malta call 112.
Interactions and side effects
Some medicines speed up the breakdown of the hormones in the liver and can make contraception less reliable: certain medicines used in epilepsy, certain medicines used in tuberculosis, some antiretrovirals and the herbal preparation St John's wort, which is sold without a prescription. A complete list of what you take therefore belongs in the assessment, supplements included.
Unlike a tablet, the ring is not affected by vomiting or diarrhoea, because absorption does not pass through the stomach. Some vaginal preparations and the use of certain products in the vagina can affect it, so it is worth asking rather than assuming.
The side effects described most often are headache, vaginal discharge or discomfort, breast tenderness, nausea, mood changes, spotting between periods and reduced desire. Spotting is most common in the first months and usually settles.
Serious events are much rarer but they are the reason for the prescription requirement: clots in veins or arteries, serious liver disorders and cardiovascular events where blood pressure is uncontrolled. A new migraine, or one that becomes different or comes with aura, is a reason to contact a doctor promptly. How often each effect occurs is in the leaflet for your pack.
Prescription status and what we can do
NuvaRing is prescription only, so a pharmacy does not supply it without a prescription. The decision to prescribe belongs to a doctor after an assessment of your medical information, which for combined contraception includes blood pressure and the risk of clots. We do not sell medicines and we do not ship them.
Whether contraception is covered by the public health service in Malta, and on what terms, is decided by the health authorities. Our service is private and is not covered by them, so the pharmacy price and our fee are two separate items. A pharmacy will tell you the current price of the pack.
Our model is a medical questionnaire that a doctor reviews asynchronously, from your answers and any records you attach. There is no video call, no phone call and no live chat with a doctor. If this method has already been started by a doctor and this is a continuation, you can ask for an assessment at /contraception/ for 24,90 €. Priority handling is available for an extra 9,90 €, which is not a promise of a deadline. A first start, a change of method or new symptoms need a doctor who can examine you.
If the doctor issues a prescription, you receive the document by email as a PDF in the standard EU cross-border format set out in Directive 2012/52/EU; its recognition in another member state is governed by Directive 2011/24/EU. There is no code and the document is not entered in any Maltese state health record, so you go to the pharmacy with a printout or with the PDF on screen, together with photo identification. A pharmacy in Malta may dispense it; the decision rests with the pharmacist. What a pharmacy checks is explained in /blog/eu-prescription-maltese-pharmacy/. The fee covers the doctor's assessment, not the issuing of a document. If the doctor declines on medical or legal grounds, we refund the fee. If we ask you for medical records, you have at least 7 days to reply. We then send a reminder and extend the deadline on request, and where the assessment still cannot be completed we close the request and refund the fee. The assessment is carried out by Damian Wojno, a doctor registered in Poland, licence no. 3211301, MEDINOW Sp. z o.o. He is not registered with the Medical Council of Malta, which keeps the register of doctors practising here.
Is NuvaRing prescription only in Malta?
Yes. It is supplied on prescription only, because it is combined hormonal contraception and carries the same class of risk as the combined pill. A doctor has to weigh up blood pressure, your history and everything else you take before it is started. A pharmacy will not supply it without a prescription, and an assessment can end in a refusal or in a recommendation of a different method.
How long does one ring last?
One ring covers one cycle: it stays in place for a set number of weeks and is then removed for a break before the next one is used. The exact intervals differ between products, so follow the patient information leaflet for your own pack and the instruction from the doctor who prescribed it rather than general advice.
Which side effects are common?
Headache, vaginal discharge or discomfort, breast tenderness, nausea, mood changes, spotting between periods and reduced desire are the most commonly described. Spotting is most common in the first months and usually settles. Warning signs of a clot, such as pain or swelling in one calf, sudden breathlessness, chest pain or a sudden severe headache with disturbed vision, mean urgent medical help.
What happens if the ring slips out?
What matters is how long it has been out and where in the cycle that happened. A short interruption is usually handled by rinsing the ring in cool or lukewarm water and putting it back; a longer one can mean reduced protection and a need for additional protection. Follow the leaflet for your own pack, and if you are unsure, treat it as the less favourable case.
Does it protect against sexually transmitted infections?
No. It acts on the possibility of pregnancy and does nothing against infections; it is not a barrier method, even though it sits in the vagina. Only barrier methods reduce the risk of infection, and they can be used together with this method.
How is a repeat prescription arranged?
If a doctor has already started this method and you are continuing with it, fill in the medical questionnaire at /contraception/. The medical assessment costs 24,90 €. A recent blood pressure reading is worth having to hand, because for combined contraception it is part of the assessment. We do not promise a deadline, because it depends on the completeness of your answers and on the doctor's assessment.