Contraceptive patch

"Evra patch" redirects here. For the brand of patch containing estradiol only, see Evorel patch.
Contraceptive patch

Ortho Evra brand of contraceptive patch
Background
Birth control type Hormonal (combined estrogen + progestin)
First use 2002
Failure rates (first year)
Perfect use 0.3%[1]
Typical use 9%[1]
Usage
User reminders Weekly application for 3 weeks
Clinic review 3-6 monthly
Advantages and disadvantages
STD protection No
Weight No proven effect
Period advantages Regulated, may be lighter and less painful
Benefits Compared to oral pills, may be less affected by antibiotics
Risks DVTs rates similar to oral combined pills

A contraceptive patch is a transdermal patch applied to the skin that releases synthetic estrogen and progestin hormones to prevent pregnancy. They have been shown to be as effective as the combined oral contraceptive pill with perfect use, and the patch may be more effective in typical use.[2][3]

The only currently available contraceptive patches are Ortho Evra, marketed in the United States by Ortho-McNeil, and Evra, marketed in Canada by Janssen-Ortho and in the United Kingdom and other countries by Janssen-Cilag. The patches are packaged in boxes of three and are only available by prescription. The contraceptive patch is often informally referred to as "the Patch."

Method of use

A woman applies her first patch onto her upper outer arm, buttocks, abdomen or thigh on either the first day of her menstrual cycle (day 1) or on the first Sunday following that day, whichever she prefers. The day of application is known from that point as patch change day. Seven days later, when patch change day comes again, the woman removes the patch and applies another to one of the approved locations on the body. This process is repeated again on the next patch change day. On the following patch change day, the patch is removed and not replaced. The woman waits 7 days without a patch in place, and on the next patch change day she applies a new patch. Extended use regimens, where patches are used for several weeks before a patch-free week, have been studied.[4]

The patch should be applied to skin that is clean, dry, and intact. This means, if skin is red, irritated, or cut, the patch should not be placed in that area. Additionally, avoid using lotions, powder, or makeup around the area where the patch is, or will be placed.[5]

Backup contraception

  • If a woman chooses to begin with her patch change day as day 1 of her menstrual cycle, the patch is able to take effect in time to prevent ovulation (see Mechanism of Action below) and no form of backup contraception is needed at all.
    • In the case that a woman wishes to begin using the contraceptive patch following a first trimester abortion or miscarriage, patch application can be done immediately afterwards. This can be considered the same as a day 1 start above, and no backup contraception is required.
  • If a woman chooses to begin with her patch change day as the first Sunday following day 1, it is necessary to use a backup form of contraception such as spermicide or condoms for the first week of patch wear.
  • If a woman is late placing her patch in the first week, or more than two days late placing the patch in the second and third weeks, she should apply the patch immediately, and then use a back up form of barrier protection for a week.[6]

Mechanism of action

Illustration depicting transdermal contraceptive patch.

Like all combined hormonal contraceptives, Ortho Evra / Evra works primarily by preventing ovulation. A secondary mechanism of action is inhibition of sperm penetration by changes in the cervical mucus. Hormonal contraceptives also have effects on the endometrium that theoretically could affect implantation; however, no scientific evidence indicates that prevention of implantation actually results from their use.[7]

The 20 cm² Ortho Evra contraceptive patch contains 750 µg ethinyl estradiol (an estrogen) and 6000 µg norelgestromin (a progestin).[8] The 20 cm² Evra contraceptive patch contains 600 µg ethinyl estradiol and 6000 µg norelgestromin.[9] The Ortho Evra contraceptive patch and the Evra contraceptive patch are both intended to gradually release into the systemic circulation approximately 20 µg/day of ethinyl estradiol and 150 µg/day of norelgestromin.[8][9]

Benefits

Because the Ortho Evra patch works similar to that of birth control pills, many of the benefits are the same. For example, the patch may make a woman's period lighter and more regular. It may also help to clear acne, decrease cramps, and reduce PMS symptoms. Additionally, the patch is associated with an increased protection against iron deficiency anemia, ovarian cysts, pelvic inflammatory disease, and endometrial and ovarian cancer.[10]

The patch is a simple and convenient form of birth control that only requires weekly attention. When a woman stops using the patch, her ability to become pregnant returns quickly.[11]

Interactions and contraindications

Contraceptive effectiveness of the patch or any other hormonal contraceptive may be reduced significantly if administered alongside various antibiotics, antifungals, anticonvulsants, or other drugs that increase metabolism of contraceptive steroids.

However, despite the interactions with many other antibiotics, a clinical pharmacokinetic drug interaction study showed that oral administration of tetracycline HCl 500 mg for 3 days prior to and 7 days during use of Ortho Evra "did not reduce effectiveness of Ortho Evra." This is a significant factor in the common decision to administer tetracycline-derived antibiotics following an abortion (preventatively to fight potential infection) when synthetic hormone contraceptives are to be used afterwards.

Drugs containing St. John's Wort are also known to affect the effectiveness of hormonal contraceptives.

It has also been found that the Ortho Evra patch is less effective in women over 198 pounds (90 kg).[10]

Side effects

In three large clinical trials involving a total of 3,330 women using the Ortho Evra / Evra patch for up to one year, 12% of users discontinued the patch because of adverse events. The most frequent adverse events leading to patch discontinuation were: nausea and/or vomiting (2.4%), application site reaction (1.9%), breast discomfort, engorgement or pain (1.9%), headache (1.1%), and emotional lability (1.0%).[12]

The most frequent adverse events reported while using the Ortho Evra / Evra patch were: breast discomfort, engorgement or pain (22%), headache (21%), application site reaction (17%), nausea (17%), upper respiratory tract infection (10%), menstrual cramps (10%), and abdominal pain (9%).[12]

Breakthrough bleeding and/or spotting while using the Ortho Evra / Evra patch was reported by: 18% in cycle 1, 12% in cycle 3, 8% in cycle 6 and cycle 13. Breakthrough bleeding (requiring more than one pad or tampon per day) was reported by: 4% in cycle 1, 3% in cycle 3 and cycle 6, and 1% in cycle 13.[13]

Overall, side effects that tend to go away after two or three months include bleeding between periods, breast tenderness, and nausea and vomiting. Symptoms that may last longer include skin irritation around the area where the patch is placed and a change in the woman's sexual desires[14]

Additional side effect information is provided in the Ortho Evra label information and the Evra Summary of Product Characteristics (SPC) and PIL.[8][9][15]

Thromboembolic risks

All combined hormonal birth control products have a very small increased risk of serious or fatal thromboembolic events. There is ongoing research into the thromboembolic risks of Ortho Evra as compared to combined oral contraceptive pills. A recent study found that users of the contraceptive patch may have a twofold increased risk for non-fatal venous thromboembolic events compared with women who took a norgestimate-containing oral contraceptive with 35 µg of estrogen.[16][17] However, a different study concluded that the risk of nonfatal venous thromboembolism for the contraceptive patch is similar to the risk for oral contraceptives containing 35 µg of ethinyl estradiol and norgestimate.[18] The contradiction in findings between the two studies is not easily resolved, because the confidence intervals for the studies are overlapping.

In studies with oral contraceptives, the risk for cardiovascular disease (such as thromboembolism) is significantly increased in women over the age of 35 years who also smoke tobacco.[19] Hence, Ortho-Evra's package insert states: "Women who use hormonal contraceptives, including ORTHO EVRA, should be strongly advised not to smoke."

According to the manufacturer, the patches introduce a 60% higher level of estrogen into the bloodstream as compared to oral contraceptives; however, the clinical significance of this difference is unknown.

On November 10, 2005 Ortho McNeil, in conjunction with the FDA, revised the label for Ortho Evra, including a new bolded warning about higher exposure to estrogen for women using the weekly patch compared to taking a daily birth control pill containing 35 µg of estrogen, noting that higher levels of estrogen may put some women at increased risk for getting blood clots. The label was again revised in September 2006, and on January 18, 2008, the FDA again updated the label to reflect study results. "The FDA believes that Ortho Evra is a safe and effective method of contraception when used according to the labeling, which recommends that women with concerns or risk factors for serious blood clots talk with their health care provider about using Ortho Evra versus other contraceptive options."[20]

Lawsuits

The Patch has been associated with strokes and thrombosis and the mechanism for hormone absorption and dissipation from the body's tissues is different from "the pill." Several lawsuits have been instigated over these issues.

A lawsuit filed in Federal Court in New Jersey on September 2, 2005 by a Georgia woman who suffered a pulmonary embolism alleges the company promoted the patch despite knowledge of its health risks, for financial gain, while failing to warn of the risks of blood clots and other injuries.

In November 2005, CBS News aired a story about documents that surfaced in a lawsuit involving a young mother who was paralyzed by a stroke and remained a total invalid, which showed the company had received nearly 500 reports of adverse events between April 2002 and December 2004. During the same time frame, only 61 adverse event reports were filed in connection with all type of birth-control pills.

The parents of a 14-year-old girl from Wisconsin have filed a lawsuit against Johnson & Johnson because they claim that she died from a blood clot that arose from her use of the Patch.

References

  1. 1 2 Trussell, James (2011). "Contraceptive efficacy". In Hatcher, Robert A.; Trussell, James; Nelson, Anita L.; Cates, Willard Jr.; Kowal, Deborah; Policar, Michael S. (eds.). Contraceptive technology (20th revised ed.). New York: Ardent Media. pp. 779–863. ISBN 978-1-59708-004-0. ISSN 0091-9721. OCLC 781956734. Table 26–1 = Table 3–2 Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception, and the percentage continuing use at the end of the first year. United States.
  2. ↑ Trussell, James (2007). "Contraceptive Efficacy". In Hatcher, Robert A.; et al. Contraceptive Technology (19th rev. ed.). New York: Ardent Media. ISBN 0-9664902-0-7.
  3. ↑ Contraceptive Technology, Chapter 12, Contraceptive Patch and Vaginal Contraceptive Ring, by Kavita Nanda, page 272
  4. ↑ Stewart FH, Kaunitz AM, Laguardia KD, Karvois DL, Fisher AC, Friedman AJ (June 2005). "Extended use of transdermal norelgestromin/ethinyl estradiol: a randomized trial". Obstet Gynecol 105 (6): 1389–96. doi:10.1097/01.AOG.0000160430.61799.f6. PMID 15932834.
  5. ↑ Mayo Clinic (2010). "Ortho Evra (Contraceptive Patch)." Retrieved from http://www.mayoclinic.com/health/ortho-evra/MY01006/DSECTION=what-you-can-expect, on February 3, 2011.
  6. ↑ Mayo Clinic. "Ortho Evra (Contraceptive Patch)." Retrieved from http://www.mayoclinic.com/health/ortho-evra/MY01006/DSECTION=what-you-can-expect, on February 3, 2011
  7. ↑ Rivera R, Yacobson I, Grimes D (1999). "The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices". Am J Obstet Gynecol 181 (5 Pt 1): 1263–9. doi:10.1016/S0002-9378(99)70120-1. PMID 10561657.
  8. 1 2 3 Ortho-McNeil Pharmaceutical (September 20, 2006). "Ortho Evra U.S. Prescribing Information" (PDF). FDA. Archived from the original (PDF) on 2007-09-26. Retrieved 2007-07-20.
  9. 1 2 3 Janssen-Cilag (January 2007). "Evra Summary of Product Characteristics (SPC)". Retrieved 2007-07-20.
  10. 1 2 Bedsider (2010). "The Patch." Retrieved from http://bedsider.org/methods/the_patch#alternatives_tab, on February 3, 2011.
  11. ↑ Planned Parenthood (2011). "Birth Control Patch (Ortho Evra)." Retrieved from http://www.plannedparenthood.org/health-topics/birth-control/birth-control-patch-ortho-evra-4240.htm, on February 3, 2011.
  12. 1 2 Sibai BM, Odlind V, Meador ML, Shangold GA, Fisher AC, Creasy GW (2002). "A comparative and pooled analysis of the safety and tolerability of the contraceptive patch (Ortho Evra/Evra)". Fertil Steril 77 (2 Suppl 2): S19–26. doi:10.1016/S0015-0282(01)03264-2. PMID 11849632.
  13. ↑ Zieman M, Guillebaud J, Weisberg E, Shangold GA, Fisher AC, Creasy GW GW (2002). "Contraceptive efficacy and cycle control with the Ortho Evra/Evra transdermal system: the analysis of pooled data". Fertil Steril 77 (2 Suppl 2): S13–8. doi:10.1016/S0015-0282(01)03275-7. PMID 11849631.
  14. ↑ Bedsider (2010). "The Patch." Retrieved from http://bedsider.org/methods/the_patch#alternatives_tab on February 3, 2011.
  15. ↑ Janssen-Cilag (January 26, 2007). "Evra Patient Information Leaflet (PIL)". Retrieved 2007-07-20.
  16. ↑ Medpage Today. Evidence on Ortho Evra Patch Thrombosis Risk Is Contradictory. Published February 17, 2006.
  17. ↑ Cole JA, Norman H, Doherty M, Walker AM (February 2007). "Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users". Obstet Gynecol 109 (2 Pt 1): 339–46. doi:10.1097/01.AOG.0000250968.82370.04. PMID 17267834.
  18. ↑ Jick S, Kaye JA, Li L, Jick H (July 2007). "Further results on the risk of nonfatal venous thromboembolism in users of the contraceptive transdermal patch compared to users of oral contraceptives containing norgestimate and 35 microg of ethinyl estradiol". Contraception 76 (1): 4–7. doi:10.1016/j.contraception.2007.03.003. PMID 17586129.
  19. ↑ Pitsavos C, Stefanadis C, Toutouzas P (2000). "Contraception in women at high risk or with established cardiovascular disease". Ann. N. Y. Acad. Sci. 900: 215–27. doi:10.1111/j.1749-6632.2000.tb06233.x. PMID 10818409.
  20. ↑ FDA Approves Update to Label on Birth Control Patch. FDA. January 18, 2008

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