What is the safest contraceptive patch for a 35-year-old who uses electronic cigarettes (e-cigs)?

Safest Contraceptive Patch for a 35-Year-Old Who Vapes

For a 35-year-old who vapes, progestin-only contraceptive methods are recommended over combined hormonal contraceptive patches due to the increased risk of cardiovascular complications. Combined hormonal contraceptive patches are classified as Category 3 or 4 (usually not recommended or contraindicated) for women aged ≥35 who smoke 1.

Risk Assessment for Combined Hormonal Contraceptive Patches

The U.S. Medical Eligibility Criteria for Contraceptive Use provides clear guidance on this issue:

• Category 3: For women aged ≥35 who smoke <15 cigarettes per day, combined hormonal methods are usually not recommended unless other methods are unavailable or unacceptable 1
• Category 4: For women aged ≥35 who smoke ≥15 cigarettes per day, combined hormonal methods represent an unacceptable health risk due to increased risk of myocardial infarction and stroke 1

While vaping is not explicitly mentioned in the guidelines, the nicotine exposure and cardiovascular effects are similar to traditional cigarettes, warranting the same precautions.

Concerns with Combined Hormonal Patches

The currently available combined hormonal contraceptive patch (Ortho Evra/Xulane containing ethinyl estradiol and norelgestromin) has additional concerns:

• Higher estrogen exposure (1.6 times higher than with low-dose combined oral contraceptives) 1
• Potential increased risk of venous thromboembolism compared to 20-35 μg estrogen oral contraceptives (odds ratios 1.2-2.2) 1
• These risks are particularly concerning for a 35-year-old who vapes

Safer Contraceptive Alternatives

Since no progestin-only contraceptive patch is currently available in the U.S., the following alternatives would be safer options:

1. Progestin-only pills (mini-pills): These work primarily by thickening cervical mucus and don't contain estrogen, making them safer for women with contraindications to estrogen 1

2. Long-acting reversible contraceptives:

   • Progestin-containing IUD
   • Progestin implant
   • Injectable progestin

3. Barrier methods: Male condoms provide the added benefit of STI protection 1

Important Considerations

• Regardless of the contraceptive method chosen, a woman who vapes should be strongly encouraged to quit due to the health risks
• If the patient strongly prefers a patch delivery system despite the risks, she should be thoroughly counseled about the increased risk of cardiovascular events
• Concomitant use of condoms is recommended for STI protection regardless of contraceptive choice

Follow-up Recommendations

• Schedule follow-up 1-3 months after initiation to assess tolerance and compliance
• Monitor blood pressure regularly
• Assess for warning signs of thromboembolism (chest pain, severe headache, vision changes, leg pain/swelling)

The safest approach for a 35-year-old who vapes is to avoid combined hormonal contraceptives, including patches, and choose a progestin-only or non-hormonal method instead.