Everything you need to know about the birth control ring

And which has higher blood clot risk: the ring or the pill?
birth control ring, nuvaring, vaginal ring,

“Why think about taking birth control every day?” This question greets visitors to the website of NuvaRing, the most well-known contraceptive ring brand in the U.S. Approved by the FDA in 2001, NuvaRing is a small, clear, flexible plastic ring inserted into the vagina. Like an IUD, it slowly releases microdoses of hormones so users don’t need to take a daily pill in order to prevent pregnancy. But unlike an IUD, which has to be inserted in a doctor’s office, NuvaRing users insert and remove their own birth control device. Since 2019, three versions of the birth control ring have been available: NuvaRing, its generic version EluRyng, and a version called Annovera that can be used continuously for up to a year.

Just “Insert, remove, repeat”?

The birth control ring is inserted into the vagina, left in place for three weeks, and removed for one week in order to cause withdrawal bleeding before replacing it to start the “cycle” again. (Reminder, here’s why you actually don’t have a cycle at all on hormonal birth control). NuvaRing and EluRyng require a new ring to be inserted each month. With Annovera, the same ring is reused for a full year. 

Inserting the birth control ring just once a month sounds simple enough, but if the ring is taken out or falls out during the three-week wearing period, things get more complicated [1][2]. Why might the ring fall out? The ring is held in place by vaginal muscles, so it may fall out if those muscles are used in certain ways. The top 3 situations in which the ring may fall out are: during your period while pulling out a tampon, during sex, or while having a bowel movement. 

What happens if the birth control ring falls out?

In order to remain effective at preventing pregnancy, the ring has to be replaced quickly (within three hours for NuvaRing, and within two hours for Annovera). If left out for longer during the first or second week of the cycle of use, users are instructed to replace it, but use “backup” contraception. If it falls out during the third week, the ring can be replaced or left out to start the one-week period.

How the vaginal ring prevents pregnancy

Like the pill, the birth control ring prevents pregnancy by releasing a combination of estrogen and progestin into the body. This suppresses ovulation, thickens the cervical mucus to inhibit the movement of sperm, and thins the uterine lining. 

The vaginal ring is sometimes prescribed for reasons other than contraception

The birth control ring isn’t just used for contraception. It may also be prescribed for menstrual symptoms like heavy periods, migraines, period pain, and PMS, though it cannot get to the root of (and therefore cannot fix) why these symptoms are occurring. Compared to the pill, women who use the birth control ring experience less breakthrough bleeding during the three-week active phase, and more regular withdrawal bleeds during the week the ring is out [3]. It is sometimes worn continuously to suppress periods completely.

The vaginal ring may cause fewer side effects than other forms of birth control….

Because it delivers hormones directly into the bloodstream through the vaginal lining (bypassing the liver and gut altogether), the birth control ring only uses half the amount of estrogen contained in the pill to do the same job. 

Avoiding the gastrointestinal (GI) system gives the ring some other relative advantages. It causes lower rates of nausea, and it also does not appear to affect glucose and lipid metabolism, making it a less risky choice than the birth control shot for women with insulin resistance or type 1 diabetes [4]. 

And at least one study found that the ring, unlike the combination pill and the patch, is just as effective in preventing pregnancy for overweight and obese women [5]. 

…But very few women use it

These benefits appear not to outweigh the downsides though, as the ring remains one of the least-used forms of birth control in the United States. Only about 1% of women reported current use between 2017 and 2019. One contributing factor may be the ring’s relatively high price tag. Like all FDA-approved birth control, the ring is free with insurance. But for the uninsured, it costs up to $220 per month, or a whopping $2,670 per year for Annovera

Birth control ring-specific side effects

Women are more likely to discontinue using the birth control ring due to physical discomfort and other adverse effects, such as vaginal infections, which affect up to 14% of ring users [2]. At least one case of toxic shock syndrome has been linked to the birth control ring, though other research has shown that the bacteria produced in infections related to the ring were not those that cause TSS [6][7].

Another serious concern related to the ring is the risk of blood clots, which a Danish study found to be nearly twice as high as risk for women on the pill and six times higher compared to those not on birth control [8].

Another serious concern related to the ring is the risk of blood clots, which a Danish study found to be nearly twice as high as risk for women on the pill and six times higher compared to those not on birth control [8]. In 2008, a lawsuit was filed claiming that the type of progestin contained by NuvaRing, etonogestrel, led to a higher risk of blood clots. While the lawsuit resulted in stronger warnings being listed on the drug label, the same type of progestin continues to be used in both NuvaRing and EluRyng. 

In 2011, 24-year-old Erika Langhart died of a double pulmonary embolism caused by the NuvaRing. 

The bottom line on the birth control ring

Yes, some women may opt for NuvaRing because it’s effective for users with high BMI or because it causes less GI upset than the Pill. But from its higher risk of blood clots compared to other forms of hormonal birth control, to the possibility of its falling out during sex or other normal daily activities, there’s plenty not to love about the birth control ring. 

Additional Reading:

Everything you need to know about Depo-Provera, the birth control shot

Your hormones during a natural cycle vs. your hormones on the Pill

Too much estrogen: The risks women on the birth control patch need to know about


[1] Koetsawang S, Ji G, Krishna U, Cuadros A, Dhall GI, Wyss R, Rodriquez la Puenta J, Andrade AT, Khan T, Kononova ES, et al. Microdose intravaginal levonorgestrel contraception: a multicentre clinical trial. II. Expulsions and removals. World Health Organization. Task Force on Long-Acting Systemic Agents for Fertility Regulation. Contraception. 1990 Feb;41(2):125-41. doi: 10.1016/0010-7824(90)90142-i. PMID: 2107055.

[2] Wieder DR, Pattimakiel L. Examining the efficacy, safety, and patient acceptability of the combined contraceptive vaginal ring (NuvaRing). Int J Womens Health. 2010 Nov 12;2:401-9. doi: 10.2147/IJWH.S6162. PMID: 21151688; PMCID: PMC2990910.

[3] Bjarnadóttir RI, Tuppurainen M, Killick SR. Comparison of cycle control with a combined contraceptive vaginal ring and oral levonorgestrel/ethinyl estradiol. Am J Obstet Gynecol. 2002 Mar;186(3):389-95. doi: 10.1067/mob.2002.121103. PMID: 11904596.

[4] Cagnacci A, Ferrari S, Tirelli A, Zanin R, Volpe A. Route of administration of contraceptives containing desogestrel/etonorgestrel and insulin sensitivity: a prospective randomized study. Contraception. 2009 Jul;80(1):34-9. doi: 10.1016/j.contraception.2009.01.012. Epub 2009 Mar 17. PMID: 19501213.

[5] Westhoff, Carolyn MD. Higher Body Weight Does Not Affect NuvaRing’s Efficacy. Obstetrics & Gynecology 105(4):p 56S, April 2005. | DOI: 10.1097/01.AOG.0000153509.19172.cd 

[6] Hashmi, et al. A double hit: Emergent guillotine amputations due to toxic shock syndrome associated with necrotizing fasciitis in the setting of a vaginal contraceptive device and pharyngitis. Chest Journal: vol 162, iss. 4, supp. A1147 (2022): doi: https://doi.org/10.1016/j.chest.2022.08.911

[7] Huang Y, Merkatz RB, Hillier SL, Roberts K, Blithe DL, Sitruk-Ware R, Creinin MD. Effects of a One Year Reusable Contraceptive Vaginal Ring on Vaginal Microflora and the Risk of Vaginal Infection: An Open-Label Prospective Evaluation. PLoS One. 2015 Aug 12;10(8):e0134460. doi: 10.1371/journal.pone.0134460. PMID: 26267119; PMCID: PMC4534458.

[8] Lidegaard O, Nielsen LH, Skovlund CW, Løkkegaard E. Venous thrombosis in users of non-oral hormonal contraception: follow-up study, Denmark 2001-10. BMJ. 2012 May 10;344:e2990. doi: 10.1136/bmj.e2990. PMID: 22577198; PMCID: PMC3349780.


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