How do I know if hormone treatment is right for me?

Most young women can take hormone medicine, however, if you have certain medical
conditions (such as a history of blood clots, high blood pressure, certain kinds of heart
disease, hepatitis, severe migraines with visual changes or numbness over parts of your body,
or if you smoke), hormonal therapy may not be an option for you. Be sure to tell your
gynecologist if you have migraine headaches with loss of vision, flashing lights,
numbness/tingling, or loss of speech. Also, it is very important to tell your GYN doctor if
anyone in your family has ever had a blood clot or stroke.

How does hormonal treatment work?

Hormonal treatment works by temporarily turning off your ovaries so you don’t ovulate
(make eggs). When you don’t ovulate, you don’t have regular periods. When you are
prescribed hormonal treatment continuously, you will rarely have periods or not have them at
all. Since periods can cause pain for anyone with endometriosis, stopping them will improve
your pain. Hormonal treatment includes the Pill, vaginal ring, an injection (once every 3
months), an IUD (which is placed in the uterus) or a hormonal implant that is inserted under
the skin in your upper arm.

Hormonal treatment with combined estrogen and

progestin:
Oral contraceptive pills (OCP’s): contain the hormones estrogen and progesterone. The goal
of the treatment is to stop your periods and pain caused from endo. Teens with endometriosis
will take OCP’s in a continuous fashion.

The vaginal ring: The vaginal ring is a small, thin, flexible rubber ring that fits inside the
vagina. Once in place it releases a combination of estrogen and progestin (hormones). If you
choose this method of hormonal treatment for your endo, you would insert the ring and leave
it in place for 3 weeks. You would then take it out and replace it with a new one right away.
(If you are sexually active, neither you nor your partner will be able to feel the ring when it is
inserted properly.)

Benefits:

 Combined estrogen and progestin hormonal therapy may decrease, and in some cases
stop endo pain.
 Most girls will only have 0–4 periods a year.
 Some young women prefer using the vaginal ring or patch because they don’t need to
remember to take it every day.

Possible side effects:

 Spotting or breakthrough bleeding can last for a few days until your body gets used to
the medicine, or as long as you are taking it.
 Some girls may have heavier bleeding or a regular period.
 Breast tenderness, mood swings, headaches, nausea, cramps, bloating, and/or weight
gain.
  There is some concern that the patch may release a higher dose of hormones than the
pill, which can increase the risk of blood clots and/or stroke.
 Some girls who use the hormone patch may have skin irritation where the patch is
worn.
 Some girls who use the vaginal ring may have vaginal irritation.
 Some girls may not have relief from their endometriosis pain.

Progesterone-only hormonal treatment:

Norethindrone acetate: Aygestin® (Norethindrone acetate) is a pill that contains only
progesterone. It is a type of hormone medicine that is often prescribed for patients that cannot
take estrogen. The dosage is 5–10mg per day.

Medroxyprogesterone Acetate (Depo–Provera®): Medroxyprogesterone acetate is another

type of medication that only contains the hormone progesterone. It is an injection that is
given once every 3 months by a nurse or your primary health care provider.
Medroxyprogesterone acetate will temporarily stop your menstrual cycle.

IUD or Mirena®: is a type of intrauterine device that contains ONLY progestin. The IUD is
most often prescribed with combination OCP’s (oral contraceptive pills) to reduce the size of
lesions caused from endometriosis and lessen the amount of bleeding.

Implants: Hormonal implants such as Nexplanon® come in the shape of a tiny tube that is
placed under the skin in the upper arm. The implant prevents pregnancy and reduces the size
of lesions caused from endometriosis. It is effective for 3 years. The implant is about the size
of a toothpick and made of a flexible plastic that contains a type of progestin hormone
medicine called etonogestrel.

Benefits:

 Progesterone–only hormone therapy can be effective in treating symptoms of

endometriosis.
 The Mirena® IUD lasts up to 5 years.
 The IUD plus oral contraceptive pills can lessen bleeding and pain from endo.
 The Nexplanon® Implant lasts for 3 years.

Possible side effects:

 Spotting or breakthrough bleeding can last for a few days until your body gets used to
the medicine, or as long as you are taking it
 Bleeding or a regular period
 Breast tenderness, nausea, bloating, weight gain, and/or hair thinning
 Headaches, mood swings including depression, nervousness
 Bone density loss and increased risk of osteoporosis (thinning of your bones) when
taken for a long time
 Some girls may not have relief from their endometriosis pain
Hormonal treatment with GnRH agonists (gonadotropin
releasing hormone agonists) and Add–Back:
The combination of GnRH agonists and hormonal add–back therapy is usually prescribed
when other hormonal medicine does not work in relieving endo pain. The goal of GnRH
agonists and add–back therapy is to stop the endometriosis from growing and lower the side
effects of GnRH therapy alone. Add–back therapy can be a small amount of progesterone, or
a combination of estrogen and progesterone.

GnRH agonists work by temporarily turning off your pituitary gland, which stops your
ovaries from making estrogen and progesterone (so you won’t have a period). Since all of the
GnRH agonists lower estrogen levels, the possible side effects for all of the medicines in this
group are the same symptoms that women often have during menopause. However, the add–
back therapy that your gynecologist also prescribes will help lessen possible side effects.

Leuprolide Acetate (Lupron–Depot®): Leuprolide acetate is one type of GnRH agonist that
is given as an intramuscular (in the muscle) injection (shot). It can be given either once a
month or once every 3 months. Our GYN team prefers that you get the injection once every 3
months so you don’t have to come in for appointments every month. Please make sure that
the shot comes in the 3 month form (blue box).

Nafarelin Acetate: Nafarelin acetate (Synarel®) is another type of GnRH agonist that comes
in the form of a nasal spray. The recommended dose is one puff in one nostril in the morning,
then another puff in the other nostril at nighttime, however dosages are sometimes adjusted.

Benefits:

 Low levels of estrogen cause your period to stop and endometriosis from growing.
 Low levels of estrogen stop endo from growing so your fertility is preserved.

Possible side effects:

 Bone density loss and higher risk of osteoporosis (thinning of your bones) when taken
without add–back therapy.
 Side effects may include hot flashes, mood swings, vaginal dryness, bone and joint
aches, hair loss, lack of interest in sex, and possible short–term memory loss.
 In many cases, teens and women may be able to stay on this treatment longer than six
months as long as their bone density is checked and is normal.
 Some girls may not have relief from their endometriosis pain.

Remember, all medicine affects each person differently. It usually takes about 2–3 months to
see an improvement in symptoms and for your body to get used to any new medicine. Side
effects will go away soon after the medication is stopped and your menstrual cycle returns.
Deciding what treatment is best for you may take some time. Talk to your GYN team about
any concerns or questions you might have. In the meantime, you can help your body feel
better by eating well and getting exercise and sleeping 8-9 hours every night.
Endometriosis: Continuous Hormonal Pills (OCPs)

Posted under Health Guides. Updated 29 August 2016.

Combination hormonal treatment is very effective for treating

endometriosis. Hormonal treatment doesn’t “cure” endometriosis, but it may help with
controlling pain by stopping your periods and preventing endometriosis from getting worse.
Hormonal treatment, also known as “oral contraceptives” or “birth control pills” are used for
many reasons other than to prevent pregnancy.

What exactly are hormonal pills?

Hormonal pills contain the hormones estrogen and progestin, which are similar to the
hormones that are normally made by the ovaries. There is also another type of pill that
contains only one hormone (progestin), and is called either the “progestin–only pill”, or the
“mini–pill”.

Are there different kinds of hormonal pills?

Yes. There are many different hormonal pills that come in a lot of different packages. The
shapes and colors of the packages may be different but there are just two categories of pills:
combined estrogen and progesterone pills (these have both estrogen and progesterone
hormone medicine in them), and progestin–only pills that contain just progesterone.
Hormonal pills come in a 21–day pill pack or a 23, 24, or 28–day pill pack. The most
common pill packs are the 21–day pack which contain all hormone pills and the 28–day pack
contains 3 weeks of hormone pills and 1 week of inactive (placebo) pills.

How do I know if hormonal pills are right for me?

Not everyone should take hormonal pills. You will be asked questions about your medical
history, such as whether you or anyone in your family has a history of blood clots. In
addition, you won’t be given estrogen pills if you have certain types of migraine headaches.
There are different doses of hormones in different hormonal pills. Your gynecologist may
prescribe a progestin–only pill if there is a medical reason why you should not take estrogen.
Please tell your GYN team if you have migraine headaches or a family history of blood clots
or strokes.
Are there other medical benefits of taking hormonal pills?

Yes. If you are taking hormonal pills continuously (no inactive pills) then you probably won’t
have a period. Hormonal pills also lower your chance of getting endometrial (lining of the
uterus) cancer and ovarian cancer, ovarian cysts, certain breast lumps, and may protect you
from osteoporosis. Hormonal treatment may also improve acne.

What is the difference between “active” and “inactive” hormonal pills?

Active pills contain hormone medicine. If your pill pack is in the shape of a rectangle, the
pills will be in 4 rows (7 pills in each row). The active pills are in the first 3 rows of your pill
pack. The inactive pills are in the last row of the 28–day pill pack and DO NOT contain
hormone medicine. If your pill pack is round, the pills will be in a circle. The active pills are
the first 21 pills and the last 7 pills are the inactive ones, and are usually a different color.

If you are using a 21–day pill pack, all the pills are active. When you are on continuous
hormonal treatment for endometriosis, you will take an “active pill” every day in a
continuous pattern.

What does “cyclic” use and “continuous” use mean?

Cyclic use means taking all the pills in the 28–day pack (21 active pills plus 7 inactive pills),
then starting the next pack. This method results in periods and is not routinely used for the
treatment of endometriosis.

Continuous use means taking active hormone pills every day without a break. If you are using
the 28–day pill pack, you will take 1 active pill a day for 3 weeks (3 complete rows) and then
start your next pill pack. You will not take the last row of inactive pills; throw them away. If
you are prescribed the 21–day pill pack, finish the entire pack (3 rows) and then start your
next pill pack the next day. Do not skip any days between pill packs. Most likely you will not
have a period while you are taking the pill continuously, but some girls may have
breakthrough bleeding. Having up to four periods a year is considered normal on this method.

What are the side effects of hormonal pills?

Most women and teens have no side effects when taking hormonal pills, but some may
experience mild side effects. Each type of hormonal pill can affect each woman or teen
differently.

Spotting: Breakthrough bleeding between periods may occur while taking the first three
weeks of hormone pills, but this is not serious. This usually happens during the first two or
three cycles. You should call the GYN team if the bleeding is heavier than a light flow, or
lasts more than a few days. It is very important that you take your hormone pills at exactly
the same time to keep your hormone levels in balance. This will lower the chance of having
breakthrough bleeding.

Nausea: You may feel queasy or nauseous at times, but this may go away if you take the Pill
with a meal or a snack. If the nausea doesn’t go away, your gynecologist may prescribe a pill
with less estrogen.
Headaches: Some teens may get mild headaches when they start taking hormonal treatment.
Although headaches usually happen because of stress or other reasons, be sure to let your
GYN team know if the headaches are severe or if they continue.

Mood changes: Mood changes or mood swings can happen when taking hormonal treatment.
Exercise and a healthy diet may help, but if they don’t, you may need to change the type of
pill you are taking.

Acne: Usually hormonal treatment helps cure acne, but some teens may get acne from a
particular pill.

Weight: Some teens gain weight, some lose weight, but most teens stay exactly the same
when they are taking the hormonal treatment.

Tip: Set your cell phone alarm to remind you to take your pill at exactly the same time every day. If
you are even 20 minutes late you may bleed or have pain.

Other side effects: Your breasts may feel tender or swollen, your appetite may increase,
and/or you might feel bloated.

Most often, side effects go away within the first 3 to 4 months of taking the hormonal pill. If
the side effects are severe or if they don’t go away after three cycles, your gynecologist may
switch you to a different hormonal pill or talk to you about other types of hormonal
treatments for your endometriosis.

Are there serious side effects I should watch out for while taking the hormonal
pill?

Most young women who take hormonal pills have few or no problems. However, if you have
any of the following problems, go to the closest emergency room right away.

 Abdominal pain (severe)

 Chest pain (severe), cough, shortness of breath
 Headache (severe), dizziness, weakness, or numbness
 Eye problems (vision loss or blurring), speech problems
 Severe leg pain (calf or thigh)

Remember: ACHES

Endometriosis: Leuprolide Acetate Instructions

Posted under Health Guides. Updated 29 August 2016.

 If your gynecologist has prescribed Leuprolide acetate (Lupron
Depot®) to treat your endometriosis, please read the following important information.

 Leuprolide acetate (3 month formulation) is an injection (shot) that is given in the buttocks,
arm or thigh every 3 months (12 weeks). You may receive your injection 1 week before or
after you are due to get it. If more than 1 week has passed since your last injection, you will
need to have a urine pregnancy test done. If it is negative, schedule an appointment to get
your next injection in 10 days.
 Depending on your health insurance coverage, you may be required to order your medicine
by mail. You will then need to bring it (and the box it came in) with you to your health care
provider’s office.
 Add–back therapy is Norethindrone acetate (Aygestin®) or Medroxyprogesterone acetate
(Prempro®). It must be taken at the same time each day.
 Oral contraceptive pills: If you are on oral contraceptive pills, continue the Pill for 3 weeks
after your first injection. On the day you stop the Pill you will begin taking the add–back
medication.
 Calcium supplements: While on Leuprolide acetate, it is important that you take a calcium
supplement, as your body needs 1300 mg of calcium every day.
 Eating and drinking foods that are high in calcium is also important.
 Vitamin D: It is recommended that teens take 600 IU’s (international units) of vitamin D
every day. Vitamin D is a pill that can be taken with calcium.
 Your first period on Leuprolide acetate: Please be aware that you may have a heavy and
painful period during the first 4–6 weeks after your first Lupron Depot® shot. After that, you
will probably not have anymore vaginal bleeding as long as you take the add–back therapy at
the same time each day.
 Appointments to get your follow–up injection: Make sure you make your appointment on a
day that your gynecologist sees patients.
 6 month follow–up visit: After 6–8 months on Leuprolide acetate and add–back, you and
your gynecologist will talk about whether or not you can continue on the medicine. If you do
continue, you will be scheduled for a DXA Scan.
 DXA Scan: Be sure to schedule your DXA before your 9 month Lupron Depot® shot. Your
gynecologist will need to review the results before you can have your next shot. A follow–up
DXA will be done every 1–2 years as needed.
 Improvement in pain: It usually takes about 2–3 months to see an improvement in
symptoms (while on Leuprolide acetate and add–back therapy).

Endometriosis: Leuprolide Acetate With Add–Back

Posted under Health Guides. Updated 29 August 2016.

 Leuprolide acetate (Lupron Depot®) is a type of gonadotropin–
releasing hormone agonist (GnRH agonist) medicine. GnRH agonist medications help to
lower pelvic pain caused by endometriosis. Add–back therapy is the addition of a small
amount of the hormones estrogen and progesterone or progesterone alone. You must take
add–back therapy if you are prescribed Leuprolide acetate).

How does Leuprolide acetate work?

This medication works by shutting off hormones made by your ovaries, so your estrogen (one
of the hormones that cause your body to have periods) level is lowered. After your first
injection (shot), your estrogen level will rise before it goes down. This is called an “estrogen
surge”. Because of this rise in estrogen, you may have an increase in your symptoms for a
few weeks. After the estrogen surge, your estrogen levels will go down. This temporarily
stops your period. When you do not have periods, endometriosis symptoms are usually
relieved.

How is Leuprolide acetate given?

Leuprolide acetate is an injection. It is very important to get your injection on time. Missed
doses can cause breakthrough bleeding and the return of pain.

How long can I take Leuprolide acetate with add–back ?

Leuprolide acetate alone is usually prescribed for 6 months (1 shot every 3 months).
However, when you take it with add–back, you can almost always stay on it longer. After a
few months of treatment you will have an appointment with your gynecologist to see if the
medicine is helping you. This appointment also gives your doctor a chance to ask you about
your pelvic pain and any other symptoms you may be having. If your symptoms are better, he
may suggest that you continue taking the medicine.

What are the side effects of taking Leuprolide acetate?

Taking Leuprolide acetate alone lowers the estrogen level in the body, which typically causes
side effects similar to menopause. These side effects may include: hot flashes, vaginal
dryness, decreased interest in sex, moodiness, headaches, spotting, and change in bone
density. However, with the addition of “add–back” therapy, you will most likely NOT
experience these side effects. If you do have symptoms, they are generally mild.
After the second month of treatment, your period will likely stop. However, you may have a light
period or spotting during treatment. It is important to get your injections on time and to stop
treatment when recommended.

What is “Add–back” therapy?

Add–back is a pill that contains a small amount of estrogen and progesterone, or

progesterone–only that is taken every day. Since hormones are important to keep your bones
healthy, low levels of hormones can lower your bone density putting you at risk for
osteoporosis (thinning of your bones). The goal of add–back therapy is to give your body
back just enough hormone(s) to protect your bones and control any unwanted side effects
such as hot flashes and vaginal dryness that are common when taking Leuprolide acetate
alone. Your gynecologist will decide on how much add–back medicine you will need, and
give you a prescription. Add–back is either: Aygestin® 5mg/daily, or Prempro®
0.625/2.5mg/daily.

When do the effects of Leuprolide acetate go away?

The effects of Leuprolide acetate will decrease after you stop taking the medicine. If you’ve
been getting Lupron® every 3 months, your period will usually return within 4 to 8 months
after your last shot. If you’ve been getting Lupron Depot® every month, your period will
likely return 6–8 weeks after your last shot. Bone density loss may be partially or completely
recovered. This means that your bones may or may not be as solid as they were before you
started the medicine.

Can I take Leuprolide acetate forever?

Research has shown that long term use of Leuprolide acetate alone can cause bone density
loss. Bone density loss is a big concern especially if you have a family history of
osteoporosis. Osteoporosis causes your bones to become fragile and break more easily.
“Add–back” therapy can help prevent loss of bone density, which may allow you to stay on
the medicine longer.

What is bone density?

Bone density is a measurement of how solid and strong your bones are. Bones need to be
strong and solid so they do not break easily. Your teenage and young adult years are
important for bone development. Weak bones during the teenage years may negatively
impact your bone health later in life. Your bones need lots of nutrients, especially calcium
and vitamin D. It is also important to eat a well–balanced diet and include foods high in
calcium.

When will I be scheduled for a bone density test?

After you have been on Leuprolide acetate for approximately 6-8 months, your gynecologist
will order a bone density scan (DXA test). This is a simple test that measures how dense (or
thick) your bones are and if your bones are thinning. If the DXA scan is normal and you
continue on the medicine, you will need to repeat the DXA test every 1-2 years.
What can I do to prevent bone loss?

You will likely be told to take calcium and vitamin D supplements. Calcium works to build
and maintain bone density. Vitamin D improves the absorption of calcium. Make sure to
divide your daily dose of calcium if taking more than 500mg. Your body can only absorb so
much at once.

Can I get pregnant when I am on Leuprolide acetate?

Although this medication works by preventing ovulation (stops you from making eggs), there
is a rare chance that you could become pregnant if you have unprotected sex. Thus, it is
important to use a non–hormonal birth control method such as condoms while on this
medication. The long term effects to an unborn baby whose mother was on Leuprolide
acetate at the time of conception are unknown at this time, but it does not appear to cause
birth defects.

Endometriosis: Progesterone-Only Treatment

Posted under Health Guides. Updated 29 August 2016.

If you are unable to take estrogen or if you do not respond to

combination (estrogen and progesterone) pills, your gynecologist may prescribe either
Norethindrone acetate (Aygestin®, Nor–QD®, or Camilla®) or Medroxyprogesterone acetate
(Depo–Provera®), different kinds of progesterone–only hormone medicine. These medicines
stop your body from ovulating and your endometriosis from growing. Most teens will not
have a period. Taking synthetic (man–made) progesterone medication in this form is very
similar to the natural progesterone that is made by your body during pregnancy.

Are there any reasons why I wouldn’t be able to take Progesterone–only

hormone therapy?

Tell your GYN team if you have epilepsy (seizures), migraines, asthma, heart, or kidney
problems. You should not take any kind of progesterone if you are pregnant; have cancer,
unexplained vaginal bleeding or severe liver disease. You should also tell the team if you
have diabetes, high blood pressure, high cholesterol or you have been diagnosed with
depression in the past.

What are the side effects?

Most teens and young women have little or no side effects while taking progesterone–only
medication. Possible side effects can include breakthrough bleeding or spotting, changes in
weight, acne, breast enlargement, feeling bloated, headache/migraines, nausea or vomiting,
and possible decrease in bone density (thinning of the bones).

Hormone medications can affect people differently. Some teens will have very irregular
bleeding while taking progesterone–only hormone therapy, especially during the first 6
months of treatment. Breakthrough bleeding is less common the longer you are on hormonal
therapy.

How is Norethindrone acetate taken?

Norethindrone acetate (Aygestin®) is a pill that you swallow.

Starting Aygestin®: Take 1-2 (5mg) tablet at the same time every day as prescribed by your
health care provider. At Boston Children’s Hospital, we currently recommend that you do not
take more than 10 mg of Aygestin®/day.

How is Nor–QD® or Camilla® taken?

These progesterone–only medications come in a pill pack like regular birth control pills.
There are 28 active hormone pills in each pack.

How is Medroxyprogesterone acetate given?

Medroxyprogesterone acetate (Depo–Provera®) is an injection that is given in a muscle (in

the buttocks, arm or thigh) every 3 months. The first shot is usually given within the first 5
days of your menstrual cycle (during your period). If you are sexually active, a routine urine
pregnancy test will be done first. The next shot needs to be scheduled within 11–13 weeks.

In addition to being as effective as other hormone therapies that treat endometriosis, both
medications protect against pregnancy but NOT sexually transmitted infections (STIs). Always use
condoms if you are sexually active.

Vaginal Hormonal Ring (NuvaRing®)

Posted under Health Guides. Updated 13 August 2014.

Key Facts
 The vaginal ring is a method of birth control that provides both
estrogen and progestin hormones. You need a prescription from your health care provider.
The vaginal ring is also used to treat conditions such as irregular periods, menstrual cramps,
or endometriosis.

Out of 100 women using the vaginal hormonal ring

Typical use: 9 women will become pregnant

Perfect use: 1 or less women become pregnant

What is the vaginal hormonal “ring”?

The vaginal hormonal ring is a method of birth control that contains estrogen and progestin,
the same hormones that are in combination birth control pills. The vaginal hormonal ring is
inserted into the vagina similar to a tampon. Once in place, the ring is left in the vagina for 3
weeks at a time. The vaginal ring is also used to treat conditions such as irregular periods,
menstrual cramps, and endometriosis.

How does the ring work?

There are two different hormones called estrogen and progestin in the vaginal ring. When the
ring is inserted in a woman’s vagina, the medicine is absorbed through the vaginal wall and
enters the bloodstream to stop the ovaries from releasing eggs. The hormones make the
cervical mucus thicker, which helps to prevent sperm from traveling upwards towards the
uterus and fallopian tubes.

Can teenagers use the ring?

Yes. The vaginal ring is easy to use and safe for most teens. The benefits include shorter,
lighter, and less painful periods. Weight gain is uncommon and unlikely to be related to the
ring. If you are thinking about using the “ring”, make sure to tell your health care provider if
you have any medical problems such as blood clots, heart problems, high blood pressure, or
severe migraine headaches with aura (such as flashing lights 5 to 30 minutes before the
migraine).

Do I need a prescription for the ring?

Yes. You do need a prescription from your health care provider (HCP) to buy the ring, but
you DON’T need to be fitted for it. One size fits all. It’s sold under the brand name
NuvaRing®. Talk to your HCP to see if you can use hormone methods such as the ring.
Cigarette smoking increases your risk for heart problems. If you smoke, work with your HCP
to quit.

Is the ring as effective as the pill in preventing pregnancy?

Yes, when used correctly. The ring is 99% effective in preventing pregnancy. Some herbal
medicines and antibiotics may lower the effectiveness of the vaginal hormonal ring.

Do I need to use condoms when I’m using the ring?

Yes. The ring does NOT prevent sexually transmitted infections (STIs), so make sure you use
condoms 100% of the time. The first cycle that you start using the ring, it may not be as
effective in preventing pregnancy, so it’s especially important for you to use condoms the
first 7 days.

How should I use the ring?

When you’ve had your questions answered and you have learned how to insert the ring,
you’re ready to begin. Fill the prescription at your pharmacy. Like other hormonal methods,
the ring can be used in a cyclic fashion with a week off or continuously with no week off.

When should I begin using the ring for the first time?

You should begin using the ring by inserting it between Day 1 and Day 5 of your menstrual
cycle. Day 1 of your cycle is the first day of your flow (bleeding). The ring should be inserted
by cycle day 5 at the very latest, even if you still have your period. Your health care provider
may also have you start using it right after your appointment (“quick start”) and use condoms
for the first cycle.

Cyclic Use (3 weeks on, 1 week off): Once you insert the ring, you should leave it in place
for 3 weeks in a row. After 3 full weeks, you will remove the ring for 1 week before you start
your next cycle. You will most likely get your period during the “ring-free” week. This is the
(7 day) break in between cycles when you are not using the ring. Your period will likely
come 2-3 days after you take the ring out of your vagina.

The calendars show examples of a cyclic ring cycle.

Continuous Use: For continuous use instructions, see our guide on Continuous Hormonal Treatment.

How do I insert the ring?

1. Before you begin, wash and dry your hands.

2. With clean hands, gently open the foil pouch that the ring comes in. Save the pouch so you
can throw the used vaginal ring away in it later.
3. Make sure you find a private place such as your room or the bathroom, so you’ll feel relaxed.
4. You may want to lie down in bed with knees bent or squat down with knees bent or stand
with one leg on a chair or toilet seat. (It’s similar to inserting a tampon.)
5. Using 1 hand (right hand if you are right handed, left if you are left handed), hold the vaginal
ring between your thumb and index finger. Hold the sides together so they are touching and
the ring is folded (see photo).
6. While holding the ring, gently insert the ring into your vagina as far as it will go. (If you don’t
want to touch your vagina to put it in, you can use a cardboard tampon container with the
tampon removed. Simply take out the tampon and place the ring inside the empty
container. Insert the container with the ring inside and push the applicator to insert the
ring.)

Will I feel the ring?

The exact position of the ring is not important for it to be effective but it should be
comfortable. Most teens and women who use the vaginal ring do not feel it once it is in place.
If you do feel it, gently push the ring a little further back into the vagina. The ring should not
hurt or cause discomfort once it is inserted and placed correctly. If it feels uncomfortable,
remove it, read the “How do I insert the ring?” directions again, and then try to insert it once
more. If you still can’t insert the ring without discomfort, stop and contact your health care
provider.

If I push the ring too far up inside my vagina, will it get lost?

No. The ring can’t get lost inside of your vagina. Your cervix, which is located at the end of
your vagina, prevents the ring from traveling up into your uterus.

How long do I leave the ring inside my vagina?

Once in place, the ring should stay inside your vagina for 3 complete weeks unless you are
having problems such as new migraine headaches or severe nausea (feeling like you want to
throw up most of the time).

If you are using the ring in a cyclic way, you will remove the ring after 3 complete weeks
and wait 1 full week before you insert a new ring. If you are using the ring continuously,
you will take the ring out after 4 complete weeks and insert a new ring right away.

Is it possible for the ring to fall out?

It’s possible but unlikely the ring will fall out. If the vaginal ring is inserted properly, the
muscles inside your vagina hold the ring in place. The ring could possibly come out if it is
not inserted high enough into your vagina, if you are very constipated, straining with a bowel
movement, or it could slip out if you are removing a tampon.

What do I do if the ring slips out?

If the ring slips out of your vagina, it’s okay to gently rinse it under cold water (not hot
water!) then re-insert the ring in your vagina as soon as possible. You must do this within 3
hours. If you wait longer than 3 hours or forget to put the ring back in your vagina, there’s a
chance that the ring will not prevent pregnancy. Place the ring back in your vagina and use a
“back up” method of contraception, such as condoms for 7 days.

Can I use tampons?

Yes. However, the ring may come out when the tampon is removed. Generally you will not
have your period during the 3 weeks while you have the ring in place. You will probably
have your period during the “ring-free week” and you won’t have to worry about using a
tampon at that time. If the ring slips out, follow the about directions.

How do I take the vaginal hormonal ring out of my vagina?

Insert your index and middle finger of one of your hands into your vagina and gently feel for
the ring. Once you feel the ring, hook your index finger around it and guide it out with your
middle finger, pulling forward until the ring comes out. This should not hurt at all because the
ring is thin and flexible.

Once I take the ring out, do I just throw it away?

It may seem silly but how you throw the ring away is very important. This is because there
may be some active medicine left on the ring. Once you have removed the ring, place it in
the foil pouch that it came in, seal the pouch, and then throw it away in the trash- away
from young children and/or pets. If you forgot to save the pouch, either wrap the ring in a
piece of aluminum foil or place it in a zip-lock plastic sandwich size bag. The ring is NOT
flushable, so DO NOT flush it down the toilet.

Do I need to take the ring out on the same day of the week that I put it in?
Yes, you should remove the ring on the same day of the week that you started. For example,
if you inserted the ring on Sunday at 9:00 pm, you will need to remove the ring 3 full weeks
later on a Sunday at about the same time, at 9:00 pm.

What if I forget to take the ring out?

If you are using the ring in a cyclic way (3 weeks on, 1 week off) and you leave the ring in for
up to 4 weeks, remove the ring, throw it away, and wait 1 week before you insert a new ring.

If you are using the ring in a continuous way, and you leave the ring in for up to 4 weeks,
remove the ring, throw it away, and insert a new ring.

If you are LESS than 48 hrs. late with inserting a new ring and you are sexually active:

 Insert the ring as soon as possible

 Keep the ring in until the scheduled ring removal day.
 Emergency contraception (EC) is not usually needed but can be considered depending on
day of your cycle.Talk to your health care provider HCP to find out if you should have a
pregnancy test or if EC is needed.

If you are MORE than 48 hrs. late with inserting a new ring and you are sexually active:

 Insert the new ring as soon as possible

 Keep the ring in until the scheduled ring removal day.
 Use back-up contraception (condoms) or avoid sexual intercourse until a ring has been worn
for 7 straight days.
 Talk to your health care provider about whether you should take Emergency Contraception
(EC) . Let your HCP know the week of your menstrual cycle.

Can I have sex while I am wearing the ring and will my partner be able to
tell?

Having intercourse is a personal decision. The ring is safe and should stay in the vagina
during intercourse. Your partner won’t usually be able to feel the ring. If the ring is a problem
during intercourse, then the ring can be removed for up to three hours. It should then be
rinsed with cold water and re-inserted into the vagina. A diaphragm (another form of birth
control) is not meant to be used with the vaginal hormonal ring. Always use condoms when
having sexual intercourse to lower your risk of getting a sexually transmitted infection (STI).

Are there any side effects with the ring?

Side effects are uncommon; but are similar to the side effects of oral contraceptive pill as it
contains the same hormones (progestin and estrogen). Occasionally women report headaches,
nausea, and breast tenderness. Other, less common side effects may include vaginal irritation.

Are there any reasons why I shouldn’t use the ring?

The ring contains the same medicine that’s in birth control pills, the hormones estrogen and
progestin, so it may not be safe for you to use if you have a history of certain medical
problems such as blood clots, high blood pressure, or serious migraine headaches. It’s very
important to tell your health care provider if you or other close family members have a
history of any of these conditions. You should not use the ring if you are breastfeeding.
Cigarette smoking greatly increases your risk for serious cardiovascular conditions, while
quitting smoking will make you healthier and using the ring safer.

Is there anything else I should know about the vaginal hormonal ring?

The combination (estrogen and progesterone) vaginal hormonal ring, EE and Nestorone®
(NES) is under development and not yet available; it may have less side effects. There’s also
a progesterone-only releasing hormonal ring that has been approved for breastfeeding
mothers. At this time the new Progering® is only available in certain areas of South America.

You and your health care provider should decide if the ring is a good choice for you., If you have
additional questions or you are having problems using the ring for the first time, call your health care
provider. Routine physical exams, and getting your blood pressure checked are important.
Remember that the vaginal hormonal ring does not prevent the spread of HIV or other sexually
transmitted infections. If you are sexually active, be sure to use condoms every time you have sex!

For more information, visit nuvaring.com.

Parts of this guide were adapted from the patient handout, The First Contraceptive Vaginal
Ring-NuvaRing. (Organon)