Females who participated in clinical studies tolerated etonogestrel; ethinyl estradiol vaginal ring well. Genitourinary adverse reactions associated with the use of the vaginal ring that occurred in 5% to 14% of patients include vaginitis and vaginal secretions (leukorrhea). Some of these symptoms may also be due to vaginal candidiasis. The most frequent events leading to discontinuation in 1% to 2.5% of patients were device-related events (foreign body sensation, coital problems, device expulsion) and vaginal symptoms (discomfort, vaginitis, leukorrhea). Vaginal erosion, cervical erosion, vaginal ulceration, and cervical ulceration in women using etonogestrel; ethinyl estradiol has been rarely reported. In some cases, the ring adhered to vaginal tissue, necessitating removal by a healthcare provider. There have been reported cases of the ring disconnecting at the weld joint; this is not expected to affect the contraceptive effectiveness of the ring. In the event of a disconnected ring, vaginal discomfort or expulsion is more likely to occur. Vaginal injury (including associated vaginal pain, discomfort, and unusual bleeding) associated with ring breakage has been reported; these reports included patients concomitantly using intravaginal antimycotic, antibiotic, and lubricant products. Also, some women are aware of the ring at random times during the 21 days of use or intercourse. During intercourse, some sexual partners may feel the ring in the vagina. However, clinical studies revealed that 90% of couples did not find this to be a problem. There have been rare reports of inadvertent insertions of the etonogestrel; ethinyl estradiol vaginal ring into the urinary bladder, which has required cystoscopic removal. Patients who are unable to locate the vaginal ring who also present with urinary symptoms should be assessed for ring insertion into the urinary bladder.[43310]

During clinical trials of the etonogestrel; ethinyl estradiol vaginal ring, headache, nausea, upper respiratory tract infection, sinusitis, and weight gain were some of the most commonly reported adverse reactions occurring in 5% to 14% of patients. Additionally, headache, emotional lability, and weight gain lead to discontinuation of therapy in 1% to 2.5% of patients. The following adverse reactions are generally common during the initiation of a hormonal contraceptive regimen and often subside after the first few months of routine use. These require medical attention only if prolonged or bothersome: abdominal discomfort or cramps, appetite stimulation, mild vomiting, fluid retention or edema with weight gain, weight loss, azotemia, breast enlargement, and fatigue. In general, etonogestrel; ethinyl estradiol vaginal ring exhibits a low incidence of these side effects. If needed and appropriate for the patient, switching to an oral contraceptive combination with a different dose strength or estrogen to progestin ratio or combination can resolve troublesome effects that continue.[43310]

Cases of toxic shock syndrome (TSS) have been associated with tampons and certain barrier contraceptives. Very rare cases of TSS have been reported by etonogestrel; ethinyl estradiol vaginal ring; in some of these cases, the women were also using tampons. Symptoms of TSS include chills, confusion, dizziness, fever, lightheadedness, myalgia, sunburn-like rash followed by peeling of the skin, hypotension, and unusual redness of the inside of the nose, mouth, throat, vagina, or conjunctivae. No causal relationship between the use of etonogestrel; ethinyl estradiol vaginal ring has been established. If an individual exhibits signs of TSS, the possibility of this diagnosis should be excluded and appropriate medical evaluation and treatment initiated.[43310]

The following additional adverse event information relates to the use of combination hormonal contraceptives as a class; in some cases the relation of listed side effects to etonogestrel; ethinyl estradiol vaginal ring use specifically is not known. Much of the adverse event information has been gathered from studies using oral contraceptives: Changes in menstrual bleeding patterns (e.g., menstrual irregularity) often occur after initiation of hormonal contraceptive therapy (e.g., the etonogestrel; ethinyl estradiol vaginal ring). Breakthrough bleeding and spotting are common during the first 3 months of administration of most hormonal contraceptives, especially in the first cycle of use. During 3 large clinical trials, 2% to 11.7% of patients during cycles 1 through 13 experienced breakthrough bleeding. These changes usually subside and are replaced by a more predictable menstrual bleeding pattern with the appropriate continuation of dosing. Amenorrhea, oligomenorrhea, and temporary infertility are occasionally reported in combination hormonal contraceptive users. If scheduled bleeding does not occur during the dose-free interval in a given monthly cycle, consider the possibility of pregnancy; in some patients, a pregnancy test may be indicated. If the patient has not adhered to the prescribed dosing schedule, consider the possibility of pregnancy at the time of the first missed period and perform a pregnancy test. If the patient has adhered to the prescribed dosing schedule and misses 2 consecutive periods, perform a pregnancy test to rule out pregnancy. Unusual or continued vaginal bleeding may prompt a need for examination.[43310]

Breast pain or tenderness (mastalgia) and galactorrhea (breast discharge) may occur during hormonal contraceptive use. Women using the etonogestrel; ethinyl estradiol vaginal ring should report any lumps or galactorrhea to their health care professionals.[43310]

When initiating therapy an individual's headache pattern should be observed and if headaches worsen or if focal neurologic findings are present, discontinue etonogestrel; ethinyl estradiol therapy and evaluate the cause.[43310] The relationship of migraine headache and the administration of hormonal contraceptives is not clearly defined. A number of changes can occur when a woman initiates hormonal contraceptive therapy and include 1) migraines can appear for the first time, 2) a change in frequency, severity and duration of headaches may be seen, or 3) an improvement or decrease in the occurrence of migraine or other headaches may occur.

Combined hormonal contraceptive use has traditionally been associated with various thromboembolic disorders. The risk for the development of deep venous thrombosis and/or pulmonary embolism is approximately 3 to 6 times greater in combined oral contraceptive (COC) users than in nonusers. In several studies, the risk of thromboembolism was reported to be higher in smokers compared with nonsmokers. Both hormone amount and hormone type may be important factors. Estrogens decrease levels of antithrombin-III and increase the production of blood clotting factors VII, VIII, IX, and X; risks increase with ethinyl estradiol doses greater than 50 mcg/day. The additional effects of progestin in combination with the estrogen may also influence embolic risk. Regarding stroke and COC use, the risk may be related to the amount of estrogen as well as the type of progestin, although this issue is controversial. Early epidemiological studies showed an increased risk for stroke; however, these studies assessed COCs containing more than 50 mcg of ethinyl estradiol. Recent literature has shown that the use of the lower dose (i.e., 35 mcg ethinyl estradiol or less) oral contraceptive combinations available today do not increase a healthy woman's risk of heart attack or stroke.[25200] [25222] Smoking remains the most significant risk factor for embolic events while on hormonal contraceptives. An increased risk of mesenteric thrombosis and intracranial bleeding have also been associated with the use of oral contraceptives and may apply to etonogestrel; ethinyl estradiol use.[43310]

Hypertension may occur with hormonal contraceptives; the prevalence increases with duration of use and patient age, and possibly increasing progestin concentration.[43310] Close monitoring of blood pressures is recommended for patients at risk for hypertension; blood pressures usually return to normal after discontinuation of etonogestrel; ethinyl estradiol therapy.

Mood or personality changes occur commonly in women taking hormonal contraceptive agents like etonogestrel; ethinyl estradiol. These changes include emotional lability, mental depression, anxiety, libido decrease, frustration, anger, or other emotional outbursts. In some cases, women discontinue hormonal contraceptives due to mood changes or emotional lability. However, hormonal contraceptives have also been reported to improve PMS and other cyclic emotional changes in some patients.[43310]

Clinical case reports of retinal thrombosis associated with oral contraceptive use exist. Optic neuritis, which may lead to partial or complete loss of vision has been reported in users of oral contraceptives, however the association has been neither confirmed nor refuted. Likewise, cataracts have been reported during oral contraceptive use without evidence of causality.[44124] Exogenous estrogen use can cause a conical cornea to develop from steepening or increased curvature of the cornea, caused by thinning of the stroma. Patients with contact lenses may develop intolerance to their lenses. Any change in vision or visual acuity should be examined by an ophthalmologist. In the event of unexplained visual impairment, onset of proptosis or diplopia, papilledema, or retinal vascular lesions, discontinue etonogestrel; ethinyl estradiol. Immediately take appropriate diagnostic and therapeutic measures.[43310]

In a pooled-data analysis from 2 large United States sites, women between the ages of 18 to 44 years old who had no prior incidence of coronary heart disease (CHD) or cerebrovascular disease prior to their MI event were studied for relative risk related to low-dose oral contraceptives. After adjustment for ethnicity and major established risk factors for CHD, there was no evidence of increased risk of myocardial infarction associated with OC use.[25200] Most other recent studies have concurred. One major exception was the WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. This international multicenter case-control study found a 5-fold increased risk of MI associated with current OC use. The authors, however, concluded that the increased risk might reflect more frequent use of OCs internationally in populations at higher risk, such as smokers and those with pre-existing cardiovascular risk factors. No increased risk of MI was in women who were non-smokers and in whom blood pressure was screened prior to OC use.[25201] Smoking is a well known additive risk to hormonal contraceptive therapy, increasing the relative risk of MI by 5-fold. There is a 10 to 12-fold increase in risk of MI in patients who use hormonal contraceptive therapy and smoke compared to females who do not smoke or use OCs. Thus, one would expect a higher incidence of MI in any woman using hormonal contraceptives with known risk factors. In addition, data from a poster of an observational study presented during the European Society of Cardiology Congress in 2007 indicate that 10 years of OC use may increase the odds of atherosclerosis (as defined by the presence of femoral or carotid artery plaque). As compared to patients never taking OCs, the presence of plaque is increased after 10 years of OC use in a single carotid artery (OR 1.17, 95% CI 1 to 1.33), bilateral carotid arteries (OR 1.42, 95% CI 1.03 to 1.84), a single femoral artery (OR 1.28, 95% CI 1.1 to 1.47), or bilateral femoral arteries (OR 1.34, 95% CI 1.05 to 1.63). More data are needed to confirm these findings.[33475] This data would be expected to apply similarly to women who use etonogestrel; ethinyl estradiol vaginal ring.

Estrogens can cause a variety of dermatological reactions. Melasma, in the form of tan or brown patches, may develop on the forehead, cheeks, temples and upper lip. These patches may persist after etonogestrel; ethinyl estradiol is discontinued. Photosensitivity can be experienced with combined contraceptive use and protective clothing and sunscreens should be employed when exposed to sunlight or UV light. Other dermatologic reactions are infrequent and include maculopapular rash, urticaria, erythema nodosum, erythema multiforme, aggravation of varicose veins, hemorrhagic eruption, alopecia, or hirsutism. Other erythematous eruptions may occur. Although combined hormonal contraceptives have been used to treat acne vulgaris, in some cases they may induce or aggravate an existing acne vulgaris. Combined hormonal contraceptives have not been shown to increase the incidence of skin cancer of any type, including melanoma. Anaphylactoid reactions, including urticaria, angioedema, and severe reactions with respiratory and circulatory symptoms have been reported during oral contraceptive use.[43310]

Some women taking combination hormonal contraceptives notice tenderness, swelling, or minor bleeding of their gums, which may lead to gingivitis. Proper attention to oral care and regular dental visits during etonogestrel; ethinyl estradiol therapy are recommended.

Abdominal pain or cramps, bloating, and cholestatic jaundice have been reported in patients receiving oral contraceptives and are believed to be drug-related. Abdominal pain can indicate cholelithiasis, cholecystitis, cholestasis, pancreatitis, or peliosis hepatis. An increased risk of gallbladder disease is associated with oral contraceptive use, but the risk may be minimal, especially with the use of oral contraceptive formulations that contain lower hormonal doses of estrogens and progestogens. In patients with familial defects of lipoprotein metabolism receiving estrogen-containing preparations, significant elevations of plasma triglycerides (hypertriglyceridemia) leading to pancreatitis have been reported. Numerous cases of bowel ischemia (ischemic colitis) have been reported during combined estrogen and progesterone use; mesenteric vein thrombus due to hypercoagulability is the proposed mechanism.[57614] Other adverse effects may include colitis, elevated hepatic enzymes, hepatitis, hyperlipidemia, diarrhea, dyspepsia, anorexia, weight loss, and Budd-Chiari syndrome or hepatic vein obstruction. Peliosis hepatis, a very rare consequence of taking estrogens and combined oral contraceptives, is characterized by the presence of blood-filled spaces.[51257] In rare cases, oral contraceptives can cause benign but dangerous liver tumors. Indirect calculations have estimated the attributable risk of hepatoma to be in the range of 3.3 cases per 100,000 for users, a risk that increases after 4 or more years of use. These benign liver tumors can rupture and cause fatal internal bleeding.[50843] Discontinue ethinyl estradiol; levonorgestrel if jaundice develops, as steroid hormones may be poorly metabolized in patients with impaired liver function. Cholestatic jaundice of pregnancy or jaundice with prior combined contraceptive use are contraindications for etonogestrel; ethinyl estradiol use.[43310]

The issue of hormonal influences on the development of cancers (new primary malignancy) has been widely researched for many decades. Most studies have been performed with combined oral contraceptives (COCs), and the risks related to combined hormonal contraceptives, regardless of route of administration, are thought to be similar. In general, the data suggest an increased risk of cervical cancer among COC users, with a decreased risk for endometrial and ovarian cancers. BREAST CANCER: Epidemiology studies have not found a consistent association between use of COCs and breast cancer risk. Studies do not show an association between ever (current or past) use of COCs and risk of breast cancer. However, some studies report a small increase in the risk of breast cancer among current or recent users (less than 6 months since last use) and current users with longer duration of COC use.[43310] [62904] Several large, well-designed observational studies have provided data regarding the risk of breast cancer with COC use.[27233] [24750] [27234] Breast cancers diagnosed in current or previous COC users tend to be less advanced clinically than in never-users. The risk of breast cancer is only slightly increased in current and recent COC users (i.e., within 10 years); however, 10 years after COC cessation, the risk of breast cancer appears to be similar to that in those patients that have never used COCs.[62647] From one large study published in 2017, the risk of breast cancer was higher among women who currently or recently used contemporary hormonal contraceptives than among women who had never used hormonal contraceptives, and this risk increased with longer durations of use; however, absolute increases in risk were small. The absolute risk of breast cancer associated with any hormonal contraceptive use was 13 per 100,000 women-years, which corresponds to 1 extra case of breast cancer for every 7,690 COC users in 1 year.[62904] Moreover, the same study data suggest that any increased risk of breast cancer usually disappears rapidly after an interruption in the use of COCs.[62904] There continues to be controversy regarding the risk of COC use in women with a family history of breast cancer (e.g., BRCA mutations). However, evidence does not suggest that the increased risk for breast cancer among women with either a family history of breast cancer or breast cancer susceptibility genes is modified by the use of COCs.[48201] Patients should be instructed to perform monthly self-breast examination and report any breast changes, lumps, or discharge to their health care professional. If breast cancer is suspected in a woman who is taking hormonal contraceptives, the contraceptive should be discontinued.[43310] CERVICAL CANCER: Some studies suggest that COC use has been associated with an increase in the risk of cervical cancer or intraepithelial neoplasia; however, such findings may be due to differences in sexual behavior, presence of the human papillomavirus (HPV) and other factors. HPV is thought to be the cause of more than 90% of all cervical cancers, although, hormonal factors may influence risk. The relative risk of invasive cervical cancer of 1.37 after 4 years of use; relative risk increased to 1.6 after 8 years of use. Because a potential for cervical dysplasia may exist, regularly evaluate patients taking COCs via cervical cytology screening as recommended per standards of care.[62647] OTHER CANCERS: A meta-analysis of 10 studies indicated significant trends for a reduced risk for endometrial and ovarian cancer with increased duration of COC use. Risk of endometrial or ovarian cancers may be reduced by up to 60% with 4 or more years of use.[25198] Data suggest COCs do not protect against hereditary forms of ovarian cancer (e.g., women who carry BRCA1 or BRCA2 gene alterations).[25199] Studies have shown an increased risk of developing hepatocellular carcinoma in long-term (more than 8 years) COC users. However, these cancers are rare in the United States, and the attributable risk (the excess incidence) of liver cancers in oral contraceptive users approaches less than 1 per million users.[62647] [43310]

Decreases in serum folate, porphyria, hyperlipidemia, and exacerbation of chorea and systemic lupus erythematosus have been reported in users of hormonal contraceptives. A cystitis-like syndrome, impaired renal function, and a hemolytic uremic syndrome have also been reported. There have been rare reports of inadvertent insertions of the etonogestrel; ethinyl estradiol vaginal ring into the urinary bladder, which has required cystoscopic removal. Patients who are unable to locate the vaginal ring who also present with urinary symptoms should be assessed for ring insertion into the urinary bladder. Lactation suppression has been reported in patients receiving combined hormonal contraceptives immediately postpartum. Additionally, impaired glucose tolerance has been reported in combined hormonal contraceptive users. In patients without diabetes, elevated blood glucose concentrations have not been reported.[43310]

Use of etonogestrel; ethinyl estradiol, as with other contraceptive steroids, may result in clinical changes that influence the results of certain laboratory tests, such as coagulation factors, lipids, glucose tolerance, and binding proteins. Specific laboratory test interference has not been reported.[43310]

Combined hormonal contraceptives (CHCs) are contraindicated in people with a current or past history of cerebrovascular disease (including stroke), coronary artery disease, or thromboembolism [including coronary thrombosis, myocardial infarction (MI), thrombophlebitis, thromboembolic disease, or valvular heart disease with complications]. CHCs have been associated with thromboembolic disease such as deep venous thrombosis (DVT) and pulmonary embolism (PE). CHCs are also generally contraindicated in thrombogenic valvular or heart rhythm diseases (e.g., atrial fibrillation or subacute bacterial infective endocarditis with valvular disease atrial fibrillation), or known inherited or acquired hyper-coagulopathic thrombophilia (e.g., protein S deficiency, protein C deficiency, Factor V Leiden, prothrombin G20210A mutation, antithrombin deficiency, antiphospholipid antibodies). People with a history of retinal thrombosis should not receive CHCs due to the potential risk of vision loss should retinal thrombosis occur due to the CHC. Because tobacco smoking increases the risk of serious cardiovascular events and thromboembolism, CHC recipients are strongly advised not to smoke. Risk is especially high for heavy smokers (15 or more cigarettes per day) over 35 years of age; therefore, CHCs are considered contraindicated for tobacco smokers more than 35 years of age. Due to association of estrogen dosage with thromboembolic risk, CHCs containing 50-mcg/day ethinyl estradiol should not be used unless medically indicated. In addition, certain progestins may increase thromboembolic risk. The overall risk of venous thromboembolism in oral CHC users has been estimated to be 3 to 9 per 10,000 woman-years. Preliminary data from a large, prospective cohort safety study suggests that the risk is greatest during the first 6 months after initially starting CHC therapy or restarting (following a break from therapy 4 weeks or more) with the same or different combination product. The risk of arterial thromboses, such as stroke or MI, is especially increased in those with other risk factors, such as pre-existing high blood pressure, renal disease, elevated lipids or cholesterol, diabetes with vascular disease, or if morbidly overweight. After a CHC is discontinued, the risk of thromboembolic disease due to CHCs gradually disappears. CHCs are also associated with increases in blood pressure (BP), and CHCs are considered contraindicated in those with uncontrolled hypertension (e.g., persistent blood pressure values of 160 mmHg systolic or 100 mmHg diastolic or greater) or hypertension with vascular disease. For all CHC users, including those with well-controlled hypertension, monitor BP at routine visits and stop the CHC if BP rises significantly. An increase in BP is more likely in older CHC users with extended duration of use. The effect of CHCs on BP may vary according to the progestin in the CHC. CHCs may also cause fluid retention, and individuals predisposed to complications from edema, such as those with chronic kidney disease (CKD) or cardiac disease should be closely monitored.[43310] [30858] [48201]

Etonogestrel; ethinyl estradiol vaginal ring may not be a suitable contraceptive for some individuals. The ring device may not be suitable for people who are more susceptible to vaginal irritation or ulceration, and caution is advised for individuals who have previously experienced toxic shock syndrome (TSS). Cases of TSS have been reported by vaginal ring users. Vaginal and cervical erosion and/or ulceration have been reported in vaginal ring recipients who were also using other contraceptive vaginal devices. Therefore, vaginal barrier contraceptive devices, such as diaphragms, cervical caps, and female condoms are not recommended as non-hormonal contraception concurrently with this vaginal ring. The use of male condoms or spermicides is acceptable.[43310] [48201]

Major surgery can increase the risk for thromboembolism from combined hormonal contraceptives (CHCs). CHCs are contraindicated when there is major surgery with prolonged immobility. If feasible, discontinue the CHC at least 4 weeks before and for 2 weeks after major surgery or other planned procedure known to have an elevated risk of thromboembolism, and during and following any prolonged immobility.[43310]

Because of the increased potential for embolic risk, combined hormonal contraceptives (CHCs) are contraindicated in people who currently have diabetes mellitus and are more than 35 years of age, diabetes mellitus with hypertension or with vascular disease or end-organ damage, or diabetes mellitus of greater than 20 years duration. People with diabetes mellitus should be observed for changes in glucose tolerance when initiating or discontinuing CHCs, since estrogens may exacerbate diabetes. Altered glucose tolerance secondary to decreased insulin sensitivity has been reported.[43310]

People who are being treated for dyslipidemia should be followed closely if they elect to use combined hormonal contraceptives (CHCs). Some progestogens may elevate LDL levels and may render the control of hyperlipidemia more difficult. Those with hypertriglyceridemia, or a family history thereof, may be at an increased risk of pancreatitis when using CHCs.[43310]

Exogenous estrogens may induce or exacerbate symptoms of angioedema in individuals with hereditary angioedema.[43310]

Combined hormonal contraceptive (CHC) products are contraindicated in people with migraine with aura or other headache that is accompanied by focal neurological symptoms. CHCs are also contraindicated in people more than 35 years of age with migraine headaches of any type. The onset or exacerbation of migraine or development of headache with a new pattern which is recurrent, persistent, or severe requires discontinuation of CHCs and evaluation of the cause. A migraine with focal neurologic visual changes should be medically evaluated, as such changes may indicate cerebrovascular events.[43310] [30858]

Estrogens, such as those in combined hormonal contraceptives (CHCs), can increase the curvature of the cornea. CHC recipients who wear contact lenses who develop visual changes or changes in lens tolerance should be assessed by an ophthalmologist.[43310] [30858]

Combined hormonal contraceptives (CHCs) are contraindicated for use in people with acute or chronic hepatic disease with abnormal liver function, such as hepatic failure, acute hepatitis or decompensated hepatic cirrhosis. Other liver conditions for which estrogen-containing birth control is inappropriate include Budd-Chiari syndrome, a liver transplant that is not working well, or benign or cancerous hepatic tumors. In general, CHCs are also contraindicated in those with a history of intrahepatic cholestasis of pregnancy or a history of significant adverse event(s) associated with previous use of a hormonal contraceptive. Discontinue the CHC if jaundice or cholestasis develops during use. Acute or chronic disturbances of liver function may necessitate CHC discontinuation until markers of liver function return to normal and CHC causation has been excluded. Patients with hepatitis C infection who are being treated with ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, are also contraindicated to receive CHCs due to a risk for elevated hepatic enzymes and hepatotoxicity. Discontinue CHCs prior to starting hepatitis C therapy with these antiviral regimens; a CHC can be restarted approximately 2 weeks following completion of these hepatitis C combination drug regimens. Estrogen therapy may cause an exacerbation of porphyria and should be used with caution in people with this condition.[43310] [48201] [70437]

Combined hormonal contraceptives (CHCs) are contraindicated in people with a current diagnosis of, or history of, breast cancer, endometrial cancer, or other known or suspected estrogen-dependent tumor, as such tumors may be hormonally-sensitive. CHCs are also contraindicated in people with abnormal uterine bleeding; evaluate such patients before use to determine if a contraindication to CHC use exists. Clinical surveillance of all individuals using CHCs is important; perform breast examinations or mammography, pelvic examination, and other diagnostic or screening tests, such as cervical cytology (pap smears), as clinically indicated or as generally recommended based on age, risk factors, and other individual needs.[43310] [48201]

Use of combined hormonal contraceptives (CHCs) is contraindicated in people with a benign or malignant liver tumor, such as hepatic adenoma or hepatocellular cancer. Benign hepatic adenomas are associated with CHC use, although the incidence of these benign tumors is rare. The attributable risk (the excess incidence) is 3.3 cases/100,000 CHC users. Rupture of hepatic adenomas may cause death through intra-abdominal hemorrhage. Studies have shown an increased risk of developing hepatocellular carcinoma in long-term (more than 8 years) CHC users. However, these cancers are extremely rare in the U.S. and the attributable risk of liver cancers in CHC users is less than 1 per million CHC users. Estrogen therapy may cause an exacerbation of hepatic hemangiomas and should be used with caution in people with this condition.[43310]

Given the increased prevalence of hypercoagulable states in people with systemic lupus erythematosus (SLE), consider the thromboembolic risk versus the benefit of combined hormonal contraceptive (CHC) use. Avoid CHCs in SLE patients with a history of venous or arterial thrombosis or the presence of a hypercoagulable state (antiphospholipid antibodies and lupus anticoagulant). If CHCs are initiated in SLE patients without hypercoagulable states, choose a low-dose estrogen contraceptive (e.g., ethinyl estradiol 35 mcg per day or less); consider use of a progestin-only contraceptive. CHCs have also been reported to induce, unmask, or exacerbate SLE; more data are needed.[31435] [48201]

Mood disorders, like depression, may be aggravated in people taking combined hormonal contraceptives (CHCs). Data regarding the association of CHCs with onset of depression or exacerbation of existing depression are limited. If significant depression occurs, the CHC should be discontinued.[43310]

Avoid combined hormonal contraceptives (CHCs) in persons with a history of chloasma gravidarum or increased sensitivity to sun and/or ultraviolet radiation exposure. Chloasma (melasma) may occur with CHC use, especially in people with a history of chloasma gravidarum.[43310]

Use combined hormonal contraceptives (CHCs) with caution in people with existing gallbladder disease as CHCs may worsen gallbladder disease. Consider discontinuing CHCs in people with symptomatic gallbladder disease or cholestatic disease. Earlier studies have reported an increased lifetime relative risk of gallbladder surgery in users of CHCs and estrogens. More recent studies, however, have shown that the relative risk of developing gallbladder disease among CHC users may be minimal. The recent findings of minimal risk may be related to the use of CHC formulations containing lower hormonal doses of estrogens and progestogens.[43310] 

The estrogen component of combined hormonal contraceptives (CHCs) may raise the serum concentrations of thyroid-binding globulin, sex hormone-binding globulin, and cortisol-binding globulin. Doses of thyroid hormone replacement for hypothyroidism may need to be increased, as indicated by clinical and laboratory monitoring for the individual. Cortisol replacement therapy (e.g., corticosteroid therapy) may also need adjusted for some individuals taking CHCs.[43310]

Preexisting morbid obesity is one factor that may increase cardiovascular or thromboembolic risks associated with combination hormonal contraceptives (CHCs). Consider the presence of obesity and other underlying risk factors that may increase the risk of cardiovascular disease or thromboembolism, particularly for people more than 35 years of age. Premarketing clinical trials of etonogestrel; ethinyl estradiol vaginal ring, excluded people with obesity [body mass index (BMI) of 30 kg/m² or more].[43310] Limited literature suggests that the effectiveness of some hormonal contraceptive formulations might decrease with increasing body mass index (BMI). However, the evidence is conflicting; there are also data to suggest that the efficacy of most CHC products (with a few known exceptions) does not seem to be compromised in those who are overweight.[48201] [66895]

Discontinue etonogestrel; ethinyl estradiol vaginal ring if pregnancy is detected as there is no reason to continue combined hormonal contraceptives (CHCs) during pregnancy. Epidemiologic studies and meta-analyses have not found an increased risk of genital or nongenital birth defects (including cardiac anomalies and limb-reduction defects) following exposure to CHCs before conception or during early pregnancy. For any CHC user who has missed 2 consecutive periods, pregnancy should be ruled out before continuing CHC use. If the CHC user has not adhered to the prescribed schedule, consider the possibility of pregnancy at the first missed period; discontinue the CHC until pregnancy is ruled out.[43310] [30858] Females using the etonogestrel; ethinyl estradiol vaginal ring may experience unscheduled (breakthrough) bleeding and spotting, especially during the first month of use; check for pregnancy if unscheduled bleeding persists or occurs after previously regular cycles with this contraceptive ring.[43310]

Product labels for combined hormonal contraceptives (CHCs) recommend avoidance if possible during breast-feeding until the lactating individual has completely weaned their child. Small amounts of hormonal contraceptive steroids (estrogens and progestins) have been identified in human milk and a few reports of effects on the infant exist, including jaundice and breast enlargement.[43310] The U.S. Medical Eligibility Criteria (USMEC) state that CHCs should not be used during the first 4 weeks after delivery because of concerns about the potential effects of estrogen on breast-feeding performance during the establishment of lactation. If a patient is breast-feeding and begins taking a CHC 4 to 6 weeks after delivery, the breastfed infant should be monitored for appetite changes, hormonal side effects, and proper weight gain/growth.[48201] One study found that low-dose CHCs (e.g., 10 mcg per day ethinyl estradiol) may not adversely affect lactation.[48200] However, a systematic review concluded that the available evidence, even from randomized controlled trials, is limited and of low quality; proper trials are needed.[48202] The World Health Organization (WHO) Contraceptive Criteria has recommendations that are more restrictive than USMEC; the WHO criteria state CHCs should not be used in breast-feeding individuals before 42 days after birth and that the disadvantages of CHC use generally outweigh the advantages between 6 weeks and 6 months after birth for individuals who are breast-feeding.[48204] Alternate contraceptive agents to consider for the breast-feeding individual include non-hormonal contraceptive methods (e.g., copper IUD, barrier methods, spermicides) and progestin-only contraceptives (e.g., medroxyprogesterone contraceptive injections, norgestrel oral contraceptive, levonorgestrel IUDs).[48201]

The U.S. Medical Eligibility Criteria state to avoid combined hormonal contraceptives (CHCs) during the first 3 weeks postpartum because of the increased risk for venous thromboembolism in the early postpartum period. Postpartum individuals with additional risk factors for venous thromboembolism (VTE) (e.g., 35 years of age or older, previous VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, obesity with a BMI of 30 kg/m² or more, postpartum hemorrhage, post-cesarean delivery, preeclampsia, or tobacco smoking) should generally not use CHCs until at least 6 weeks after delivery. CHCs may be used after 6 weeks postpartum without restriction if no other contraindications to CHCs exist, as postpartum thromboembolism risk returns to baseline.[48201]