What is the proper protocol for prescribing the Evra (norelgestromin and ethinyl estradiol) patch?

How to Prescribe the Evra Patch

Apply one patch weekly for 3 consecutive weeks to the abdomen, upper torso, upper outer arm, or buttocks, followed by 1 patch-free week, with the buttock being the most preferred site among adolescents. 1

Initial Prescribing Protocol

Patient Selection and Counseling

• Screen for contraindications including active or history of venous thromboembolism, arterial disease, breast cancer, hepatic disease, undiagnosed vaginal bleeding, and pregnancy 2
• Assess weight carefully: The patch may be less effective in women weighing more than 198 pounds (90 kg), with perfect use failure rates of 0.9% versus 0.3% in lighter women 1, 3
• Counsel about increased estrogen exposure: The patch delivers 1.6 times higher estrogen exposure than low-dose combined oral contraceptives, with potentially increased venous thromboembolism risk 1, 4

Dosing and Application Instructions

• Each patch delivers 150 mcg norelgestromin and 35 mcg ethinyl estradiol daily over 7 days 5, 1
• Application schedule: Apply 1 patch weekly for 3 weeks, then 1 week patch-free (21/7 cycle) 1, 4
• Application sites: Abdomen, upper torso, upper outer arm, or buttocks—rotate sites to minimize skin irritation 1, 5
• Apply immediately upon removal from pouch to clean, dry skin 5

Starting the Patch

• Same-day initiation is recommended for immediate contraceptive effect 2
• No backup contraception needed if started within the first 5 days of menses 2
• If started at other times: Use backup contraception (condoms) for 7 consecutive days 2

Managing Delayed Application or Detachment

If Delayed/Detached <48 Hours

• Apply a new patch immediately (if detachment occurred <24 hours since application, try to reapply or replace) 2
• Keep the same patch-change day 2
• No additional contraceptive protection needed 2
• Emergency contraception not usually needed but consider if delayed application occurred earlier in the cycle or in the last week of the previous cycle 2

If Delayed/Detached ≥48 Hours

• Apply a new patch as soon as possible 2
• Keep the same patch-change day 2
• Use backup contraception (condoms) or avoid intercourse until a patch has been worn for 7 consecutive days 2
• If delayed application occurred in week 3: Omit the hormone-free week by finishing the third week of patch use and starting a new patch immediately 2
• Emergency contraception should be considered if delayed application occurred during the first week and unprotected intercourse occurred in the previous 5 days 2

Important Clinical Considerations

Efficacy and Compliance

• Typical use failure rate is 9%, similar to combined oral contraceptives 1, 2
• Perfect use failure rate is <1% in women under 198 pounds 1
• Compliance is significantly higher than with oral contraceptives, particularly important for adolescents 6, 7
• Patch detachment rates are low: 1.8% complete detachment, 2.9% partial detachment requiring replacement 6, 8

Safety Profile and Monitoring

• Baseline assessment: Confirm pregnancy status and measure blood pressure 2
• Ongoing monitoring: Assess blood pressure and overall health status changes 2
• VTE risk: Studies show mixed results, but risk may be approximately twice that of combined oral contraceptives, though absolute risk remains low 4
• Common adverse effects: Breast tenderness (22%), application site reactions (17%), and slightly longer menstrual periods 8, 6

Critical Pitfalls to Avoid

• Do not prescribe to women >198 pounds without counseling about reduced efficacy 1, 3
• Do not ignore the increased estrogen exposure: Other methods may be safer first-line choices for extended cycling 1
• Proper disposal is essential: Used patches contain large amounts of active substances and must be placed in provided sachets and returned to pharmacy 8
• Store at controlled room temperature (20-25°C) and do not store unpouched 5

When Patch May Be Optimal Choice

Despite increased estrogen exposure and VTE concerns, the patch remains an important contraceptive alternative that may be the best option for some patients, especially when considering the risks associated with unplanned pregnancy and the significantly improved compliance compared to daily oral contraceptives 1, 6. The weekly dosing regimen is particularly valuable for women who struggle with daily pill adherence 7.