What are the considerations and alternatives for using the birth control patch (Ortho Evra, containing estrogen and progestin) for contraception?

Birth Control Patch: Considerations and Alternatives

The birth control patch (Ortho Evra) is generally effective but carries a higher risk of venous thromboembolism compared to low-dose combined oral contraceptives due to 1.6 times higher estrogen exposure, making alternative contraceptive methods potentially safer first-line choices for many women. 1, 2

Efficacy and Mechanism

• Typical use failure rate: 9% (similar to combined oral contraceptives)
• Perfect use failure rate: <1% 2
• Contains combination hormones (estrogen and progestin) that work similarly to oral contraceptives
• Less effective in women weighing more than 198 pounds (0.9% vs 0.3% failure rate in first 12 months) 1, 2

Application and Usage

• Applied to abdomen, upper torso, upper outer arm, or buttocks
• Standard regimen: One patch weekly for 3 weeks, followed by 1 patch-free week
• Extended cycling option: One patch weekly for 12 consecutive weeks, followed by a patch-free week 2
• Approximately 5% of users experience at least one patch detachment 3
• Most popular application site among adolescents is the buttock (40%) followed by lower abdomen (32%) 4

Advantages

• Simplified weekly regimen compared to daily pills
• Some studies show better compliance than oral contraceptives 3, 5
• Provides excellent cycle control with regular periods 4
• Not affected by gastrointestinal disturbances like vomiting 6

Safety Concerns and Side Effects

• Higher venous thromboembolism risk: FDA black box warning cites studies showing odds ratios of 1.2-2.2 compared to standard COCs 1, 2
• Common side effects similar to other combined hormonal methods:
  • Headache
  • Nausea
  • Breast tenderness/discomfort (particularly in first 2 cycles)
  • Application site reactions (64% in adolescents) 4, 7
• Unique side effects:
  • Skin effects: hyperpigmentation, contact dermatitis, irritation
  • Patch detachment or corner peeling 1, 4

Alternative Contraceptive Options

1. For women concerned about VTE risk:

   • Progestin-only methods (mini-pills, implants, injections)
   • Copper or hormonal IUDs 1, 2

2. For women >198 pounds:

   • IUDs or implants (more effective options)
   • Injectable contraceptives 2

3. For women seeking non-daily methods with lower estrogen exposure:

   • Vaginal ring (NuvaRing) - can be used for up to 35 days continuously
   • Hormonal IUDs
   • Implants 1

Decision Algorithm for Contraceptive Selection

1. Assess VTE risk factors:

   • If present (smoking, hypertension, migraines with aura, age >35): avoid patch, consider progestin-only or non-hormonal methods
   • If absent: patch may be appropriate

2. Consider body weight:

   • If >198 pounds: consider more effective methods like IUDs or implants
   • If <198 pounds: patch effectiveness is comparable to other combined methods

3. Evaluate adherence capability:

   • If poor daily adherence: patch may offer advantage over pills
   • If concerned about visibility or skin reactions: consider vaginal ring or other methods

4. Consider menstrual-related conditions:

   • For conditions improved by hormonal regulation (dysmenorrhea, heavy bleeding): patch can be beneficial, especially with extended cycling

Monitoring and Follow-up

• Follow-up recommended 1-3 months after initiation to assess tolerance and compliance
• Monitor for side effects, particularly breakthrough bleeding and skin reactions 2
• Emphasize importance of condom use for STI protection regardless of contraceptive choice 4