CP, a 21-year-old female, presents to her local community pharmacy with a new prescription for NuvaRing from her primary care physician.  She has no significant past medical history other than a diagnosis of depression, and pharmacy records indicate that she is taking Zoloft 25 mg by mouth daily.  CP states that she has never been on a birth control medication and is nervous to start now because she is unsure of how to use this new medication and is expressing hesitation.

As the pharmacist, what is an important counseling point for CP regarding NuvaRing?

A. Zoloft reduces the efficacy of NuvaRing.  CP should consult with her primary care physician before starting this form of birth control

B. If the ring is out of the vagina for >24 hours it counts as a missed dose

C. The NuvaRing vaginal ring is inserted and kept in place for 3 weeks, then removed for 1 week

D. CP upon receiving the Nuvaring may stored at room temperature for up to 28 days

Answer with rationale:

Learning the different prescription birth control products becomes easier when you break down the different products based on which hormonal components they contain (if any).  The pill, patch, and ring products are combined hormonal contraception which means they contain both progestin and estrogen.  There are also pills that only contain progestin (known as progestin only pills) as well as implants and IUDs (which are forms of long-acting reversible contraception).  The only non-hormonal prescription birth control option currently available is the copper IUD.

It is important to remember that other than the copper IUD all forms of prescription birth control must contain progestin to be effective.  Estrogen is often used as an adjunctive contraceptive agent, but it is not required.  Progestin works by thickening the cervical mucus thereby preventing sperm penetration and blocking the LH surge to suppress ovulation.  Estrogen works by suppressing the FSH released from the pituitary and by working with progestin to block the LH surge to suppress ovulation.

Answer A is incorrect.  Zoloft is the brand name of sertraline, a selective serotonin reuptake inhibitor (SSRI).  There are currently no known interactions between sertraline and NuvaRing, and SSRIs and combined hormonal contraception (CHC) products are both safe and effective when taken together.  The main drug interactions to be aware of with CHC are with antibiotics like rifampin and rifabutin, lamotrigine, certain other anticonvulsants (like phenobarbital, phenytoin, carbamazepine, etc.), and certain protease inhibitors like ritonavir contained within Paxlovid. 

Answer B is incorrect.  If NuvaRing is out of the vagina for a period >3 continuous hours, it counts as a missed dose.  If this occurs in weeks 1 or 2 after insertion, the ring must be reinserted immediately and barrier methods of contraception must be used until the new ring has been in place for 7 days.  If this occurs in week 3 after insertion, the ring must be discarded.  Then, either a new ring must be inserted immediately or if the previous ring was in place for at least 7 days before being removed, a new ring can be inserted within the 7 days after the previous ring was removed.  No matter which method is chosen, barrier methods of contraception must be used until the new ring has been in place for 7 days.

Answer C is correct.  One NuvaRing is inserted into the vagina, and it stays in place for a period of three weeks after which it is removed for a 1-week break.  This 1-week break is when the withdrawal bleeding occurs (withdrawal of estrogen stimulates menstrual bleeding).  A new ring is inserted 1 week after the last ring was removed even if menstrual bleeding has not yet finished.

Answer D is incorrect.  NuvaRing may be stored at room temperature for up to 4 months after dispensing. It should be kept in the refrigerator prior to dispensing to the patient.

Brands/generics covered:

NuvaRing (etonogestrel/ethinyl estradiol vaginal ring), Zoloft (sertraline)

NAPLEX content domains covered:

1.A.1

Domain 1 Foundational Knowledge for Pharmacy Practice- A. Pharmaceutical Science Principles and Concepts 1. Pharmacology

2.A.1

Domain 2 Medication Use Process- A. Prescriptions and Medication Order Interpretation 1. Drug Names and Therapeutic Classes

2.A.2

Domain 2 Medication Use Process- A. Prescriptions and Medication Order Interpretation 2. Indications, Usage, and Dosing Regimens

3.C.3

Domain 3 Person-Centered Assessment and Treatment Planning- C. Patient Health Conditions, including special populations and medication-related factors 3. Interactions (eg, drug-drug, drug-condition, drug-food, drug-allergy, drug-laboratory)

3.C.7

Domain 3 Person-Centered Assessment and Treatment Planning- C. Patient Health Conditions, including special populations and medication-related factors 7. Adherence

3.E.2

Domain 3 Person-Centered Assessment and Treatment Planning- E. Patient education 2. Medication use, storage, and disposal