Birth Control Pills vs. Nuvaring

• Birth control pills (oral contraceptives) and Nuvaring (etonogestrel/ethinyl estradiol) are methods of birth control used to prevent pregnancy.
• Birth control pills are taken orally while Nuvaring is a vaginal ring inserted intravaginally.
• Side effects of birth control pills and Nuvaring that are similar include nausea, headache, breast tenderness, weight changes, vaginal bleeding between periods (spotting)
• Side effects of birth control pills that are different from Nuvaring include irregular bleeding, scanty menstrual periods, and mood changes.
• Side effects of Nuvaring that are different from birth control pills include vaginal discomfort/irritation, vomiting, bloating, and swelling of the ankles/feet (fluid retention).

Birth control pills (oral contraceptives) are a birth control method used to prevent pregnancy. Birth control pills are hormonal preparations that prevent pregnancy by inhibiting the release of the hormones luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary gland in the brain. LH and FSH play key roles in the development of the egg and preparation of the lining of the uterus for implantation of the embryo. Progestin also makes the uterine lining that surrounds the egg more difficult for sperm to penetrate which makes it harder for fertilization to take place. Progestin can also inhibit ovulation (release of the egg).

Nuvaring (etonogestrel/ethinyl estradiol) is a vaginal ring containing a combination of the hormones a progestin and an estrogen and is used to prevent pregnancy. Nuvaring works by preventing the release of an egg (ovulation) during the menstrual cycle. It also makes vaginal fluid thicker to help prevent sperm from reaching an egg (fertilization) and changes the lining of the uterus to prevent attachment of a fertilized egg. If a fertilized egg does not attach to the uterus, it passes out of the body. This product does not protect against sexually transmitted diseases.

Birth Control Pills

The most common side effects of the birth control pills include nausea, headache, breast tenderness, weight gain, irregular bleeding, and mood changes. These side effects often subside after a few months' use. Scanty menstrual periods or breakthrough bleeding may occur but are often temporary, and neither side effect is serious. Women with a history of migraines may notice an increase in migraine frequency. On the other hand, women whose migraines are triggered by fluctuations in their own hormone levels may notice improvement in migraines with oral contraceptive use because of the more uniform hormone levels during oral contraceptive use. Uncommonly, oral contraceptives may contribute to increased blood pressure, blood clots, heart attack, and stroke. Women who smoke, especially those over 35, and women with certain medical conditions, such as a history of blood clots or breast or endometrial cancer, may be advised against taking oral contraceptives, as these conditions can increase the adverse risks of oral contraceptives.

Nuvaring

NuvaRing may cause serious side effects, including: blood clots. Like pregnancy, combination hormonal birth control methods increase the risk of serious blood clots (see following graph), especially in women who have other risk factors, such as smoking, obesity, or age greater than 35. This increased risk is highest when you first start using a combination hormonal birth control method or when you restart the same or different combination hormonal birth control method after not using it for a month or more. Talk with your healthcare provider about your risk of getting a blood clot before using NuvaRing or before deciding which type of birth control is right for you. In some studies of women who used NuvaRing, the risk of getting a blood clot was similar to the risk in women who used combination birth control pills. Other studies have reported that the risk of blood clots was higher for women who use combination birth control pills containing desogestrel (a progestin similar to the progestin in NuvaRing) than for women who use combination birth control pills that do not contain desogestrel. It is possible to die or be permanently disabled from a problem caused by a blood clot, such as heart attack or stroke. Some examples of serious blood clots are blood clots in the:

• legs (deep vein thrombosis)
• lungs (pulmonary embolus)
• eyes (loss of eyesight)
• heart (heart attack)
• brain (stroke)

To put the risk of developing a blood clot into perspective: If 10,000 women who are not pregnant and do not use hormonal birth control are followed for one year, between 1 and 5 of these women will develop a blood clot. The figure below shows the likelihood of developing a serious blood clot for women who are not pregnant and do not use hormonal birth control, for women who use hormonal birth control, for pregnant women, and for women in the first 12 weeks after delivering a baby.

Birth Control Pills

Many of the birth control pills come in easy-to-use dispensers in which the day of the week or a consecutive number (1, 2, 3, etc.) is written on the dispenser with a corresponding tablet for each day or number.

For example, some Ortho-Novum dispensers are labeled "Sunday" next to the first tablet. Thus, the first tablet is to be taken on the first Sunday after menstruation begins (the first Sunday following the first day of a woman's period). If her period begins on Sunday, the first tablet should be taken on that day.

For birth control pills that use consecutive numbers, the first tablet (#1) is taken on the first day of the menstrual period (the first day of bleeding). Tablet #2 is taken on the second day and so on.

Still other packages instruct women to begin on day five of the cycle. For such products, women count from day one of their menstrual cycle (day one is the first day of bleeding). On the fifth day, the first tablet is taken. Tablets then are taken daily.

Most birth control pills are packaged as 21-day or 28-day units. For 21-day packages, tablets are taken daily for 21 days. This is followed by a seven-day period during which no birth control pills are taken. Then the cycle repeats.

For the 28-day units, tablets containing medication are taken for 21 consecutive days, followed by a seven-day period during which placebo tablets (containing no medication) are taken.

Newer formulations with 24 days of hormone pills and only four days of placebo pills are now available, as are continuous or extended-cycle oral contraceptive regimens, in which only active hormone pills are taken. Extended-cycle preparations include seven-day intervals of placebo pills to be taken approximately every three months.

Women just starting to take birth control pills should use additional contraception for the first seven days of use because pregnancy may occur during this period.

If women forget to take tablets, pregnancy may result. If a single tablet is forgotten, it should be taken as soon as it is realized that it is forgotten. If more than one tablet is forgotten, the instructions that come with the packaging should be consulted, or a physician or pharmacist should be called.

Nuvaring

Use NuvaRing exactly as your healthcare provider tells you to use it. • NuvaRing is used in a 4 week cycle. o Insert 1 NuvaRing in the vagina and keep it in place for 3 weeks (21 days).

• Remove the NuvaRing for a 1 week break (7 days). During the 1-week break (7 days), you will usually have your menstrual period.

Note: Insert and remove NuvaRing on the same day of the week and at the same time:

• For example, if you insert your NuvaRing on a Monday at 8:00 am, you should remove it on the Monday 3 weeks later at 8:00 am.
• After your 1 week (7 days) break, you should insert a new NuvaRing on the next Monday at 8:00 am.

While using NuvaRing, you should not use a vaginal diaphragm as your back-up method of birth control because NuvaRing may interfere with the correct placement and position of a diaphragm.

• Use of spermicides or vaginal yeast products will not make NuvaRing less effective at preventing pregnancy.
• Use of tampons will not make NuvaRing less effective or stop NuvaRing from working.
• If NuvaRing has been left inside your vagina for more than 4 weeks (28 days), you may not be protected from pregnancy and you should see your healthcare provider to be sure you are not pregnant. Until you know the results of your pregnancy test, you should use an extra method of birth control, such as male condoms with spermicide, until the new NuvaRing has been in place for 7 days in a row.
• Do not use more than 1 NuvaRing at a time. Too much hormonal birth control medicine in your body may cause nausea, vomiting, or vaginal bleeding. Your healthcare provider should examine you at least 1 time a year to see if you have any signs of side effects from using NuvaRing.

Birth Control Pills

Estrogens can inhibit the metabolism (elimination) of cyclosporine, resulting in increased cyclosporine blood levels. Such increased blood levels can result in kidney and/or liver damage. If this combination cannot be avoided, cyclosporine concentrations can be monitored, and the dose of cyclosporine can be adjusted to assure that its blood levels do not become elevated.

Estrogens appear to increase the risk of liver disease in patients receiving dantrolene (Dantrium) through an unknown mechanism. Women over 35 years of age and those with a history of liver disease are especially at risk.

Estrogens increase the liver's ability to manufacture clotting factors. Because of this, patients receiving warfarin (Coumadin) need to be monitored for loss of anticoagulant (blood thinning) effect if an estrogen is begun.

A number of medications, including some antibiotics and antiseizure medications, can decrease the blood levels of oral contraceptive hormones, but an actual decrease in the effectiveness of the oral contraceptive has not been convincingly proven. Nonetheless, because of this theoretical possibility, some physicians recommend backup contraceptive methods during antibiotic use. Examples of medications that increase the elimination of estrogens include

• carbamazepine (Tegretol),
• phenobarbital,
• phenytoin (Dilantin),
• primidone (Mysoline),
• rifampin (Rifadin),
• rifabutin (Mycobutin), and
• ritonavir (Norvir).

Birth control pills with higher concentrations of estrogen or alternative forms of contraception may be necessary in women using those medications.

Nuvaring

Some medicines and herbal products may make hormonal birth control less effective, including, but not limited to:

• certain anti-seizure medicines (such as barbiturates, carbamazepine, felbamate, oxcarbazepine, phenytoin, rufinamide, topiramate)
• medicine to treat fungal infections (griseofulvin)
• certain combinations of HIV medicines, (such as nelfinavir, ritonavir darunavir/ritonavir, (fos)amprenavir/ritonavir, lopinavir/ritonavir, and tipranavir/ritonaivr)
• certain hepatitis C (HCV) medicines (such as boceprevir, telaprevir)
• non-nucleoside reverse transcriptase inhibitors (such as nevirapine)
• medicine to treat tuberculosis (such as rifampicin and rifabutin)
• medicine to treat high blood pressure in the vessels of the lung (bosentan)
• medicine to treat chemotherapy-induced nausea and vomiting (aprepitant)
• St. John’s wort

Use an additional birth control method (such as a male condom with spermicide) when you take medicines that may make NuvaRing less effective. Continue back-up birth control for 28 days after stopping the medicine to help prevent you from becoming pregnant. Some medicines and grapefruit juice may increase the level of ethinyl estradiol in your blood if used together, including:

• the pain reliever acetaminophen
• ascorbic acid (vitamin C)
• medicines that affect how your liver breaks down other medicines (such as itraconazole, ketoconazole, voriconazole, and fluconazole)
• certain HIV medicines (atazanavir/ritonavir, indinavir)
• non-nucleoside reverse transcriptase inhibitors (such as etravirine)
• medicines to lower cholesterol such as atorvastatin and rosuvastatin Hormonal birth control methods may interact with lamotrigine, a medicine used for seizures. This may increase the risk of seizures, so your healthcare provider may need to adjust your dose of lamotrigine.

Women on thyroid replacement therapy may need increased doses of thyroid hormone. Ask your healthcare provider if you are not sure if you take any of the medicines listed above. Know the medicines you take. Keep a list of them to show your doctor and pharmacist when you get a new medicine.

Birth Control Pills

Use of birth control pills during lactation has been associated with decreased milk production, decreased infant weight gain, and decreased nitrogen and protein content of milk. The amount of estrogen consumed by an infant whose mother takes a standard dose of birth control pills is considered to be the same as from a lactating woman who is not taking birth control pills, and side effects have not been reported. Using a progestin-only product is most often recommended during lactation if birth control pills are to be used during this period. The American College of Obstetrics and Gynecology (ACOG) recommends delaying taking combined estrogen-progestin contraceptives until at least six weeks postpartum, while the World Health Organization (WHO) recommends delaying the initiation of combined contraceptives until six months.

Nuvaring

There is little or no increased risk of birth defects in women who inadvertently use CHCs during early pregnancy. Epidemiologic studies and meta-analyses have not found an increased risk of genital or non-genital birth defects (including cardiac anomalies and limb-reduction defects) following exposure to low dose CHCs prior to conception or during early pregnancy.

The effects of NuvaRing in nursing mothers have not been evaluated and are unknown. When possible, advise the nursing mother to use other forms of contraception until she has completely weaned her child. CHCs can reduce milk production in breastfeeding mothers. This is less likely to occur once breastfeeding is well-established; however, it can occur at any time in some women. Small amounts of contraceptive steroids and/or metabolites are present in breast milk.