What is the best contraceptive patch for a 16-year-old with oligomenorrhea (infrequent menstruation), specifically seeking a regimen with only 4 periods per year?

Best Contraceptive Patch for a 16-Year-Old Wanting Only 4 Periods Per Year

For a 16-year-old seeking contraception with only 4 periods per year, the Ortho Evra transdermal patch (0.6 mg norelgestromin and 0.75 mg ethinyl estradiol) used in an extended cycling regimen is the most appropriate option. 1

Patch Selection and Dosing

The Ortho Evra patch contains 0.6 mg norelgestromin and 0.75 mg ethinyl estradiol and is applied as follows:

• Standard application sites: Abdomen, upper torso, upper outer arm, or buttocks
• Extended cycling regimen: Apply 1 patch weekly for 12 consecutive weeks (3 patches per month for 3 months), followed by a patch-free week to allow withdrawal bleeding
• Replacement schedule: Change patch once weekly on the same day of the week
• Total regimen: This creates a pattern of 4 periods per year (one every 3 months)

Administration Instructions

1. Initial application: Apply first patch within first 5 days of menstrual cycle
2. Weekly changes: Replace patch on the same day each week for 12 consecutive weeks
3. Patch-free week: After 12 weeks, remove patch and remain patch-free for 1 week to allow withdrawal bleeding
4. Restart cycle: Begin a new 12-week cycle after the patch-free week
5. Backup contraception: Use backup method (condoms) for first 7 days of initial patch use 1

Efficacy and Considerations

The patch has a typical-use failure rate of approximately 9% (perfect use <1%), making it moderately effective 1. Extended cycling with the patch provides several benefits:

• Reduced frequency of menstrual periods (4 per year as requested)
• Decreased menstrual bleeding and cramping
• Improvement in conditions exacerbated by menstruation 2

Important Safety Considerations

The patch carries some important safety considerations that should be discussed:

• Higher estrogen exposure: The patch delivers 1.6 times higher estrogen exposure than combined oral contraceptives 1
• VTE risk: The patch has a black box warning citing studies suggesting a possible increased risk of venous thromboembolism compared with 20-35 μg estrogen oral contraceptives (odds ratios 1.2-2.2) 1
• Common side effects: Application site reactions, breast discomfort (especially in first 2 cycles), and breakthrough bleeding 3, 4

Monitoring and Follow-up

• Schedule follow-up 1-3 months after initiation to assess tolerance and compliance
• Monitor for side effects, particularly breakthrough bleeding which is most common in first few cycles
• Assess patch adhesion issues (complete detachment occurs in only about 1.8% of applications) 4

Patient Counseling Points

• Compliance advantage: Weekly application may improve compliance compared to daily pills (88.2% perfect compliance with patch vs. 77.7% with pills) 4
• Breakthrough bleeding: May occur, especially during first few cycles
• Extended cycling benefits: Fewer periods, potentially less anemia, reduced menstrual symptoms
• Warning signs: Instruct to seek immediate medical attention for severe headache, chest pain, severe leg pain, or visual changes

While other contraceptive options could be used in extended cycling regimens, the patch offers the advantage of weekly rather than daily administration, which may improve compliance in adolescents while meeting the patient's specific request for only 4 periods per year.