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etonogestrel and ethinyl estradiol vaginal ring
Pharmacologic class: Sex hormone
Therapeutic class: Contraceptive
Pregnancy risk category X
Inhibits ovulation by altering cervical mucosa and endometrium of uterus. This inhibition prevents sperm from entering the uterus, thereby preventing implantation.
Vaginal ring: 0.12 mg etonogestrel and 0.015 mg ethinyl estradiol delivered daily over 3 weeks
Indications and dosages
➣ To prevent pregnancy
Adults: Place one ring into vagina and leave in place for 3 weeks, then remove for 1 week. Insert next ring on same day of week as in previous cycle.
• Hypersensitivity to drug or its components
• Breast and uterine cancers or other known or suspected estrogen-dependent neoplasms
• Valvular heart disease with complications
• Thromboembolic disease (current or previous)
• Severe hypertension
• Diabetes with vascular involvement
• Headache with focal neurologic symptoms
• Hepatic tumors, cholestatic jaundice
• Major surgery with prolonged immobilization
• Undiagnosed vaginal bleeding
• Patients older than age 35 who smoke more than 15 cigarettes daily
• Pregnancy or breastfeeding
Use cautiously in:
• underlying cardiovascular disease, severe hepatic or renal disease, asthma, bone disease, migraines, breast disease, seizures, sexually transmitted diseases
• family history of breast or genital tract cancers.
• Be aware that the best way to insert ring is with patient lying down, squatting, or standing and one leg raised.
CNS: headache, migraines, dizziness, lethargy, depression, increased risk of cerebrovascular accident, seizures
CV: hypertension, myocardial infarction, thromboembolism
EENT: worsening of myopia or astigmatism
GI: nausea, vomiting, abdominal cramps, bloating, pancreatitis
GU: amenorrhea, dysmenorrhea, cervical erosion, breakthrough bleeding, loss of libido, vaginal candidiasis, erectile dysfunction, testicular atrophy, breast tenderness, breast enlargement or secretion, increased risk of endometrial and breast cancer
Hepatic: cholestatic jaundice, hepatic adenoma
Metabolic: sodium and fluid retention
Respiratory: pulmonary embolism
Other: increased appetite, weight changes, edema
Drug-drug. Acetaminophen: decreased acetaminophen blood level
Anti-infectives, barbiturates, carbamazepine, fosphenytoin, rifampin: decreased contraceptive efficacy
Corticosteroids: increased corticosteroid effects
Cyclosporine: increased risk of cyclosporine toxicity
CYP3A4 inhibitors (such as itraconazole, ketoconazole): increased hormone levels
Dantrolene, other hepatotoxic drugs: increased risk of hepatotoxicity
Hypoglycemics, warfarin: altered requirements for these drugs
Miconazole (vaginal capsules): increased hormone levels
Phenytoin: loss of seizure control
Protease inhibitors: increased contraceptive metabolism
Tamoxifen: interference with tamoxifen efficacy
Tricyclic antidepressants: reduced antidepressant effects
Drug-diagnostic tests. Antithrombin III, folate, low-density lipoproteins, pyridoxine, total cholesterol: decreased levels
Cortisol; factors VII, VIII, IX, and X; glucose; high-density lipoproteins; phospholipids; prolactin; prothrombin; sodium; triglycerides: increased levels
Drug-food. Caffeine: increased caffeine blood level
Drug-herbs. Black cohosh: increased risk of adverse reactions
Red clover: interference with contraceptive action
Saw palmetto: antiestrogenic effects St. John's wort: decreased contraceptive blood level and effects
Drug-behaviors. Smoking: increased risk of adverse cardiovascular reactions
☞ Monitor CNS status. Report adverse CNS reactions immediately.
☞ Assess blood pressure frequently. If significant elevation of blood pressure occurs, discontinue NuvaRing.
• Monitor patient for depression.
☞ Watch for jaundice and liver engorgement; be aware that combination hormonal contraceptives may worsen existing gallbladder disease and may accelerate development of this disease in previously asymptomatic women. Discontinue drug if jaundice develops.
☞ Be aware that retinal thrombosis has been associated with the use of hormonal contraceptives. Discontinue NuvaRing if unexplained partial or complete loss of vision, onset of proptosis or diplopia, papilledema, or retinal vascular lesions occur. Take appropriate diagnostic and therapeutic measures immediately.
• Monitor glucose, calcium, and electrolyte levels and lipid profile.
• Explain that for continued contraception, a new implant must be inserted exactly 1 week after old one is removed, even if patient is menstruating.
• Tell patient to insert and remove ring on same day of week and at same time of day.
• Tell patient that if ring slips out, she should replace it within 3 hours to ensure adequate contraceptive protection.
• Inform patient that smoking during therapy may increase risk of blood clots, phlebitis, and stroke.
☞ Tell patient to immediately report signs and symptoms of depression, sudden chest pain, difficulty breathing, or yellowing of skin or eyes.
☞ Tell patient to stop drug and immediately report unexplained partial or complete loss of vision, onset of proptosis or diplopia, papilledema, or retinal vascular lesions.
• Teach patient how to perform breast self-examinations. Emphasize importance of monthly checks.
• Tell patient that this product doesn't protect against HIV infection (AIDS) and other sexually transmitted diseases.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, herbs, and behaviors mentioned above.