Screening and Contraindications for the Evra Patch

Essential Baseline Assessments

• The American Academy of Dermatology recommends pregnancy testing to confirm the patient is not pregnant before initiation of the Evra patch 1, 2
• The American Academy of Dermatology recommends measuring blood pressure to identify uncontrolled hypertension before prescribing the Evra patch 1, 2
• The Centers for Disease Control and Prevention recommends that pelvic examination is NOT necessary before prescribing the Evra patch 3
• The Centers for Disease Control and Prevention recommends that breast examination is NOT required for asymptomatic women of reproductive age 3, 4
• The Centers for Disease Control and Prevention recommends that laboratory tests are NOT needed in healthy women, including lipid panels, liver enzymes, or coagulation studies 3, 4

Critical Contraindications to Screen For

• The American Academy of Dermatology recommends screening for a history of thromboembolic events, such as deep vein thrombosis or pulmonary embolism, as an absolute contraindication to the Evra patch 1, 2
• The American Academy of Dermatology recommends screening for a history of stroke or myocardial infarction as an absolute contraindication to the Evra patch 1, 2
• The American Academy of Dermatology recommends screening for known thrombogenic mutations or hypercoagulopathies as an absolute contraindication to the Evra patch 1, 2
• The American Academy of Dermatology recommends screening for uncontrolled hypertension (systolic ≥160 or diastolic ≥100 mmHg) as an absolute contraindication to the Evra patch 1, 2
• The American Academy of Dermatology recommends screening for smoking in women ≥35 years of age as an absolute contraindication to the Evra patch 1, 2
• The American Academy of Dermatology recommends screening for migraine headaches with focal neurologic symptoms or aura if ≥35 years as an absolute contraindication to the Evra patch 1, 2
• The American Academy of Dermatology recommends screening for active liver disease or hepatic tumors (benign or malignant) as an absolute contraindication to the Evra patch 1, 2
• The American Academy of Dermatology recommends screening for a history of cholestatic jaundice with prior hormonal contraceptive use as an absolute contraindication to the Evra patch 2
• The American Academy of Dermatology recommends screening for current or history of breast cancer as an absolute contraindication to the Evra patch 1, 2
• The American Academy of Dermatology recommends screening for estrogen- or progestin-sensitive cancers as an absolute contraindication to the Evra patch 1, 2
• The American Academy of Dermatology recommends screening for undiagnosed abnormal vaginal bleeding as an absolute contraindication to the Evra patch 1, 2
• The American Academy of Dermatology recommends screening for pregnancy as an absolute contraindication to the Evra patch 1, 2

Important Clinical Considerations

• The American Academy of Pediatrics notes that the Evra patch delivers 1.6 times higher estrogen exposure than low-dose combined oral contraceptives, raising concerns about venous thromboembolism risk 5
• The Centers for Disease Control and Prevention recommends that smoking status is critical when prescribing the Evra patch, and it is absolutely contraindicated in women ≥35 years who smoke 1, 2

Ongoing Monitoring

• The American Academy of Dermatology recommends routine follow-up after initiation of the Evra patch, including blood pressure monitoring 1, 2
• The Centers for Disease Control and Prevention recommends assessment of satisfaction with the method and evaluation for any health status changes that would affect continued safe use of the Evra patch 4

Contraceptive Patch Guidelines

Introduction to Contraceptive Patches

• The transdermal contraceptive patch contains norelgestromin (a progestin) and ethinyl estradiol (an estrogen), delivering approximately 150 mcg of norelgestromin and 35 mcg of ethinyl estradiol daily to the systemic circulation 6, 7
• Each patch measures approximately 1.75 × 1.75 inches and is designed to be worn for 7 days 8

Administration and Usage Guidelines

• The patch is applied to the abdomen, upper torso, upper outer arm, or buttocks, with the buttock being the most preferred application site among adolescents (40%) 6
• Usage involves applying 1 patch for each of 3 weeks in a row, followed by 1 week without a patch, during which a withdrawal bleed usually occurs 6, 8

Efficacy and Considerations

• Typical use failure rates are similar to those of combined oral contraceptives at approximately 9% 6, 7
• Perfect use failure rate is less than 1%, but is slightly higher for women who weigh more than 198 pounds (0.9%) compared to women who weigh less (0.3%) 6, 8
• The FDA has identified increased estrogen exposure (1.6 times higher than with a low-dose combined oral contraceptive) and a potential increased risk of venous thromboembolism with the patch 6, 8

Important Considerations for Healthcare Providers

• The patch may be less effective in women weighing more than 198 pounds 6, 8
• The patch has undergone multiple label revisions due to concerns about increased estrogen exposure and VTE risk 8
• Other methods may be safer first-line choices for patients interested in extended cycling due to the increased estrogen exposure 8
• Despite potential risks, 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 8

Contraceptive Patch Prescribing Guidelines

Patient Selection and Counseling

• The American Academy of Dermatology recommends screening for contraindications, including active or history of venous thromboembolism, arterial disease, breast cancer, hepatic disease, undiagnosed vaginal bleeding, and pregnancy, before prescribing the contraceptive patch 9

Initial Prescribing Protocol

• The American Academy of Pediatrics recommends same-day initiation of the contraceptive patch for immediate contraceptive effect 10
• The American Academy of Family Physicians recommends that no backup contraception is needed if the patch is started within the first 5 days of menses, but if started at other times, backup contraception should be used for 7 consecutive days 11

Managing Delayed Application or Detachment

• The Centers for Disease Control and Prevention recommends applying a new patch immediately if delayed or detached less than 48 hours, and keeping the same patch-change day 12
• The American Academy of Family Physicians recommends using backup contraception or avoiding intercourse until a patch has been worn for 7 consecutive days if delayed or detached 48 hours or more 11
• The Centers for Disease Control and Prevention recommends considering emergency contraception if delayed application occurred during the first week and unprotected intercourse occurred in the previous 5 days 12

Important Clinical Considerations

• The American Academy of Pediatrics notes that typical use failure rate of the contraceptive patch is 9%, similar to combined oral contraceptives 10
• The Journal of the American Academy of Dermatology recommends baseline assessment, including confirmation of pregnancy status and measurement of blood pressure, and ongoing monitoring of blood pressure and overall health status changes 9