What is the best birth control (contraceptive) patch?

Best Birth Control Patch

The transdermal contraceptive patch (Ortho Evra/Xulane) containing norelgestromin 0.6 mg and ethinyl estradiol 0.75 mg is currently the only FDA-approved contraceptive patch available in the United States, making it the default "best" option by virtue of being the sole marketed product. 1

Key Product Specifications

• Dosing regimen: One patch applied weekly for 3 consecutive weeks, followed by 1 patch-free week 1
• Application sites: Abdomen, upper torso, upper outer arm, or buttocks 1
• Hormone delivery: Delivers norelgestromin 150 mcg and ethinyl estradiol 20 mcg daily to systemic circulation 2
• Efficacy: Perfect use failure rate <1%; typical use failure rate 9% 1

Critical Safety Considerations

The patch carries a black box warning for increased venous thromboembolism (VTE) risk compared to combined oral contraceptives. 1

• Estrogen exposure: 1.6 times higher than standard COCs 1
• VTE risk: Odds ratios of 1.2 to 2.2 compared to 20-35 mcg COCs, though only one of five US studies showed statistically significant findings 1
• Clinical context: Despite VTE concerns, unplanned pregnancy itself carries increased VTE risk, making the patch still a reasonable option for appropriate candidates 1

Advantages Over Oral Contraceptives

• Improved compliance potential: Weekly dosing eliminates daily pill-taking 1, 2
• Better adherence demonstrated: Patch users showed significantly better compliance than COC users in multiple trials (OR 2.05,95% CI 1.83-2.29; OR 2.76,95% CI 2.35-3.24) 3
• Stable hormone levels: Transdermal delivery avoids gastrointestinal absorption variability, hepatic first-pass metabolism, and peaks/troughs seen with oral contraceptives 4, 5
• Excellent adhesion: Less than 2% of patches required replacement due to complete detachment 2

Important Limitations

Patch users have higher discontinuation rates than COC users, which undermines the theoretical compliance advantage. 3

• Early discontinuation: ORs ranging from 1.56 to 2.57 for stopping the patch versus COCs 3
• Discontinuation due to adverse events: Patch users more likely to stop due to side effects 3
• Real-world continuation: Only 57% of patch users continued at 1 year compared to 76% of pill users in one prospective study of 1,230 women 1

Side Effect Profile

Patch users experience more breast discomfort, dysmenorrhea, nausea, and vomiting compared to COC users. 3

• Application site reactions: Can occur but are generally well-tolerated 2, 6
• Cycle control: One trial showed patch users had less breakthrough bleeding and spotting than COC users 3

Clinical Decision Algorithm

Use the patch when:

• Patient has difficulty with daily pill adherence but can manage weekly tasks 1
• Patient has no increased VTE risk factors (obesity, smoking over age 35, thrombophilia, prolonged immobility) 1
• Patient prefers non-oral, non-invasive contraception 2

Avoid the patch when:

• Patient has VTE risk factors given the 1.6-fold higher estrogen exposure 1
• Patient desires extended cycling (other methods may be safer first-line choices) 1
• Patient weighs >90 kg (efficacy may be reduced, though not explicitly contraindicated) 1

Practical Management

For delayed application or detachment <48 hours: Apply new patch immediately, keep same patch change day, no backup contraception needed 1

For delayed application or detachment ≥48 hours: Apply new patch immediately, use backup contraception for 7 days, consider emergency contraception if occurred in first week with recent unprotected intercourse 1