Contraceptive patch

The contraceptive patch is a form of contraception which contains oestrogen and progestogen hormones, similar to the combined oral contraceptive (COC) pill. The patch sticks to the skin. If used correctly, it is a very effective form of contraception.

What is the contraceptive patch?

The patch is essentially the same type of contraception as the COC pill (often referred to as 'the pill') but as a patch instead of taking pills. The contraceptive patch is stuck on to the skin so that the two hormones are continuously delivered to the body, giving contraceptive cover. You can read about the COC pill in more depth.

There is one combined contraceptive patch available in the UK, called Evra®. The contraceptive patch is available from your GP, family planning clinic or sexual health clinic.

How does the contraceptive patch work?

The contraceptive patch works mainly by changing the body's hormonal balance so that you do not produce an egg every month (ovulate). It also makes the cervical mucus thicker, forming a plug in the neck of the womb (cervix). This makes it difficult for sperm to get through to the womb (uterus) to fertilise an egg. The hormones in the contraceptive patch also make the lining of the womb thinner, so it is less likely that a fertilised egg will be able to attach to the womb.

How effective is the contraceptive patch?

Between 3-90 women in 1,000 using the contraceptive patch will become pregnant each year. It is about as effective as the COC pill. When no contraception is used, more than 800 in 1,000 sexually active women become pregnant within one year.

Why would I choose the contraceptive patch?

• It is very effective and easy to use.

• It does not interfere with sex.

• Your periods are often lighter, less painful and more regular when you are using the contraceptive patch.

• You do not have to remember to take your Pill every day but just have to remember to change the patch once a week.

• The patch is small and discreet so people won't easily notice that you are wearing it. It is skin-coloured and is about 5 cm x 5 cm in size.

• The patch sticks well to your skin and can be worn continuously, even while you are bathing, showering, exercising and swimming.

The other advantages of the contraceptive patch are thought to be similar to those of the COC pill. However, because it is a newer form of contraception, there have not been as many research studies with the contraceptive patch as there have been with the COC pill. For example, the contraceptive patch may relieve premenstrual tension. It may also reduce the risk of pelvic infection, as the mucous plug may prevent germs (bacteria), as well as sperm, from getting into the womb (uterus). However if you are at risk of sexually transmitted infection, you should also use a condom for protection. It may help to protect against some non-cancerous (benign) breast disease. It may reduce the risk of developing certain types of cyst in the ovary. It may reduce the risk of developing cancers of the ovary, colon and womb.

Contraceptive patch side-effects

Some women have skin irritation when they use the contraceptive patch. This is usually itching, redness or soreness. About 2 in 100 women have to stop using the patch because of skin irritation. Even though the patch sticks well most of the time, there is a possibility that it can become detached from the skin, either totally or partially. This is not common but can mean that its effectiveness as contraception can be lost. Despite its discreet design, some women still feel that the contraceptive patch can be seen.

Some women have some other mild side-effects when they first start using the contraceptive patch. If side-effects do occur, they tend to settle down within the first few months. Possible side-effects can include:

• Breast discomfort and tenderness.

• Slight changes in body weight. These weight changes are small and are similar to those that can occur with the COC pill. Studies have shown the patch does not cause significant weight gain.

• Headaches.

• Feeling sick (nausea).

• Mood changes.

• Bleeding between your periods, and spotting (light, irregular bleeding).

Who cannot use the contraceptive patch?

Most women can use the contraceptive patch. Your doctor or family planning nurse will discuss any current and past diseases that you have had. They may also ask about any health problems in your family. It will not be prescribed to some women with a history of certain diseases or who are at increased risk of developing certain diseases. In particular, some women with an increased risk of having a blood clot (thrombosis) may be advised not to use the contraceptive patch (see below). For example, if you smoke and are over the age of 35 years, it is thought your risk of thrombosis is too high for the patch to be safe for you.

If you are breastfeeding you should not use the contraceptive patch until your baby is 6 weeks old. If you have had a baby and are not breastfeeding, you may be able to use the patch from 3-6 weeks after your baby is born. Your doctor, midwife or nurse will be able to advise. You should not use the contraceptive patch if you are, or you think you may be, pregnant.

The contraceptive patch is less effective in women who weigh over 90 kg and it is generally advised that it should not be used for these women. Women with liver or gallbladder problems or women who have unexplained vaginal bleeding (for example, after sex or between their periods) may also not be able to use the contraceptive patch. Other conditions which may mean the patch is not suitable for you include very high blood pressure, heart problems, migraine and, in some cases, diabetes. The doctor prescribing the patch for you will need to know all your medical history in order to make the decision that it is safe for you personally.

Are there any risks in using the contraceptive patch?

The risks in using the contraceptive patch are thought to be similar to those when using the COC pill because the patch contains similar hormones. For most women, the benefits far outweigh the risks, as the risks are small. However, a small number of women who use the contraceptive patch may develop serious problems. When the patch is prescribed, you are asked about any current or past diseases that you have had and any family history of health problems. This means women who are at a greater risk of developing serious side-effects are usually prevented from using the contraceptive patch. The serious side-effects that can occur in some women include the following:

Thrombosis

This means a clot in a blood vessel and it can be very serious. A blood clot in an artery can cause a stroke or a heart attack. A blood clot in a vein, called a deep vein thrombosis (DVT), can travel through the veins and cause a blood clot in the lung. This is called a pulmonary embolism.

The following situations increase the risk of thrombosis and you may be advised not to use the contraceptive patch in these circumstances:

• If you have had a previous DVT or pulmonary embolism.

• If you are very overweight.

• Immobility (for example, wheelchair-bound, or after a major operation).

• Poorly controlled diabetes which has led to problems with your eyes, feet or kidneys.

• High blood pressure that is not adequately controlled.

• If you have a close family member who has had a thrombosis before the age of 45 years.

• Severe migraine. Specifically, migraine with "aura". This means other symptoms that occur before the headache, such as changes in your vision, numbness or not being able to talk properly.

• If you smoke - particularly if you are aged over 35 years.

• If you have had a heart attack, stroke, "mini-stroke" (transient ischaemic attack) or have angina.

• Some other rare conditions. These include having heart abnormalities, or diseases which affect your blood clotting system.

See a doctor straightaway if you have any of the following whilst using the patch:

• Severe headache.

• Bad pains in the chest or leg.

• Leg swelling.

• Breathing difficulty.

• Coughing up blood.

• Sudden problems with sight or speech.

• Vision problems.

• Weakness or numbness in an arm or a leg.

• Collapse.

Cancer

There is a small increased risk of developing breast cancer in women who use combined hormonal contraception such as the contraceptive patch. You should not use the contraceptive patch if you currently have breast cancer or have had breast cancer in the past. If you have a strong family history of breast cancer, you should discuss with your doctor the pros and cons of starting the contraceptive patch.

There may also be a small increased risk of developing cancer of the neck of the womb (cervix) for women using combined hormonal contraception such as the contraceptive patch. However, it seems to protect slightly from cancers of the ovary, the womb (uterus) and bowel.

How do I use the contraceptive patch?

When to start the patch

You should ideally start using the patch on the first day of your period. This means that the patch will start working straightaway as a contraceptive. You will be protected from becoming pregnant from the first day you use the patch if you start on the first day. If you start the patch on day 2 to day 5 of your cycle (the first day of your period is day 1) you should also be protected straightaway. If you start the patch on any other day in your menstrual cycle, you should be sure that you are not pregnant. If you then start on the patch, you cannot rely on it for contraception for the first seven days. So, you should then use an additional method of contraception (such as condoms) for the first seven days. Alternatively, after starting the patch, you could wait for seven days before having sex.

Applying the patch

The contraceptive patch should be applied to clean, dry, non-hairy skin. Do not use any lotions, make-up, creams, powders or anything else on the area of skin before you apply the patch. These can interfere with the stickiness of the patch and make it more likely to fall off. Do not use on areas of skin that are irritated or broken. Suitable places to apply the patch are the upper outer arm, upper back area, the buttocks or the lower part of the tummy (abdomen). Do not apply the patch to the breasts. You should use a different place each time you change your patch. This will help to avoid skin irritation. You should check each day to make sure that the patch has not fallen off.

You should follow the manufacturer's instructions on the packet when discarding the patch after use, as it still contains some active hormones.

When to change the patch

You wear a patch every day for three weeks. The patch needs to be removed and changed every week. After three weeks (and three patches) you will have a patch-free break for one week. During the fourth week, when you are not wearing a patch, you should have your period.

Imagine your menstrual cycle as being 28 days long. Day 1 of your cycle is the first day of your period. Follow these instructions:

• Apply the patch for the first time on the first day of your period (day 1).

• Wear the patch for seven days (week 1).

• On day 8, remove the used patch and apply a new patch immediately. You are now in week 2.

• Wear the new patch for seven days again. On day 15, remove the used patch and apply another new patch immediately. You are now in week 3.

• Wear the new patch for seven days again. On day 22, remove the patch.

• Do not wear a patch between day 22 and day 28 (week 4). You should have a bleed just like your period during this time. You are still protected from getting pregnant, provided that you apply your next patch on time.

• Start your next four-week cycle the day after day 28. Apply a new patch on this day. This starts you on day 1 again. You should apply this patch no matter when your period begins or ends.

You will change your patch on the same day every week. If you are concerned about remembering to change your patch, you can set an alarm on a mobile phone to remind you.

Alternative ways to change your patch

We now know that there are no health benefits to taking a hormone-free week (when you do not wear a patch) and having a bleed every month. Some women will want to use the patch in this 'standard' way, but all women should be given the choice to tailor the timing of their patches. This includes:

• Changing your patch at the same time every week without ever taking a week off.

• Changing your patch every week for three weeks, and starting the next three-week. cycle of patches 4 (rather than 7) days later. This may cut your risk of unplanned pregnancy.

• Wearing a patch for nine weeks running, followed by a 4- or 7-day break.

• Changing your patch every week until you bleed for 3-4 days in a row - at this stage you take a break of 4 or 7 days before you put a new patch on.

Although using the patch in this way means you may have fewer, or no, periods, you are more likely to have irregular bleeding. However, if you continue to apply your patches in the same way, this may settle down.

What do I do when I want to stop using the patch?

This depends on your plan for contraception after the patch. If you do not need contraception any more, either because you plan to have a baby or because you are not in a relationship, you can just stop it any time. Ideally stop it at the end of week 3 when you would normally come to the end of the cycle. If you do this, it will cause less disruption to your monthly bleeding cycle. However, if you wish to take the patch off before the end of the cycle, you may do so any time as long as you have not had unprotected sex in the previous five days.

If you still need contraception then speak with your doctor or nurse about how to swap to a different type of contraception in a way which will provide continuous protection as you swap over.

What if my contraceptive patch falls off?

It is unlikely that your contraceptive patch will fall off, as it has been carefully designed to minimise this.

If the patch has been off for less than 48 hours:

• Reapply it as quickly as possible (if it is still sticky).

• If it is not still sticky, replace it with a new patch. Do not use anything (such as tape) to try to hold a patch in place that is no longer sticky.

• You are still protected and do not need to use any additional contraceptive methods.

• Continue to use your patch as normal and change it on your normal day.

If the patch has been off for 48 hours or longer, or if the time that it has been detached is uncertain:

• Start a whole new patch cycle by applying a new patch as soon as possible. This is now week 1 of the patch cycle. It may also mean that you have a new day of the week for changing your patches and starting new cycles.

• If you have sex within the following seven days, you need to use additional contraception such as condoms.

• You may need to take additional emergency contraception if you have had sex within the previous five days. If this is the case, you should discuss this with your GP, practice nurse, family planning clinic or sexual health clinic.

What if I forget to change my contraceptive patch?

If you forget to take your patch off at the end of week 1 or week 2

If the delay in changing the patch is less than 48 hours:

• Replace the old patch with a new patch as soon as possible.

• Continue using the patch as normal, changing it on the usual day.

• You do not need to use any extra contraceptive precautions.

If the delay in changing the patch is more than 48 hours:

• Replace the old patch with a new patch as soon as possible.

• This is now week 1 of the patch cycle. It may also mean that you have a new day of the week for changing your patches and starting new cycles.

• If you have sex within the following seven days, you need to use additional contraception such as condoms.

• You may need to take additional emergency contraception if you have had sex within the previous five days. If this is the case, you should discuss this with your GP, practice nurse, family planning clinic or sexual health clinic.

If you forget to take the patch off at the end of week 3

• Take the patch off as soon as possible.

• Apply the next patch on the usual start day of the next patch cycle. This may mean that you do not have a seven-day patch-free break.

If you forget to put on a new patch at the end of the patch-free week

If the delay in changing the patch is less than 48 hours:

• Put a new patch on as soon as possible.

• This is now week 1 of the new patch cycle. It may also mean that you have a new day of the week for changing your patches and starting new cycles.

• You do not need to use any extra contraceptive precautions.

If the delay in changing the patch is more than 48 hours:

• Apply a new patch as soon as possible.

• This is now week 1 of the new patch cycle. It may also mean that you have a new day of the week for changing your patches and starting new cycles.

• If you have sex within the following seven days, you need to use additional contraception such as condoms.

• You may need to take additional emergency contraception if you have had sex within the previous five days. If this is the case, you should discuss this with your GP, practice nurse, family planning clinic or sexual health clinic.

Do other medicines interfere with the contraceptive patch?

Some medicines can interfere with it and make it less effective. You should always discuss all other medication that you are taking with the person prescribing the patch. This includes over-the-counter medications (such as St John's wort) which may also interfere with the contraceptive patch. If you are starting a new medication, make sure that you tell the person prescribing it that you are using the contraceptive patch. You may need to use extra contraceptive precautions (such as condoms) while you are taking the other medication and for a period of time after it is finished.

Some commonly encountered medicines that can interfere with the contraceptive patch include certain antibiotics (for example, rifampicin or rifabutin), some medicines used to treat epilepsy (anticonvulsants), some medicines used for HIV infection, and, as mentioned above, St John's wort (a herbal remedy used to treat low mood).

Note: antibiotics which are commonly used (for example, to treat a chest infection or urine infection) do not interfere with the effectiveness of the contraceptive patch.

What if I am vomiting or have diarrhoea?

If you are being sick (vomiting) or have diarrhoea, the contraceptive patch is still effective (unlike when you are taking the pill). This is because the hormones are absorbed into your bloodstream through your skin, rather than through your stomach and gut (gastrointestinal tract). You do not need to use extra contraceptive precautions.

What happens if I don't have a withdrawal bleed (like a period) between patches?

Sometimes not all women have a bleed during their patch-free week. If you have used your contraceptive patch properly, if it has not fallen off and if you have not taken any medication that may interfere with the patch, you are unlikely to be pregnant. If you are worried, you can do a pregnancy test or you can visit your GP, practice nurse, family planning clinic or sexual health clinic for advice. If you miss two periods, you should seek medical advice.

Bleeding whilst using the contraceptive patch (breakthrough bleeding)

During the first few months while your body is adjusting to the contraceptive patch, you may have some vaginal bleeding in addition to the usual bleeding during your patch-free week. This is not serious but can be a nuisance. It may vary from spotting to a heavier loss like a light period. Do not stop using your patch. This usually settles after the first 2-3 months. If it persists, see your doctor or nurse.

Can I avoid the withdrawal bleed?

You can choose to miss your monthly withdrawal bleed (period). To do this, do not have a patch-free week. When you get to the end of week 3, simply put on another patch and start the cycle as if it is week 1. This will not always work, and you may have some breakthrough bleeding. If you have used the patch correctly every seven days, you are unlikely to be pregnant. If you prefer not to have a period or withdrawal bleed at all, you could consider other methods of contraception instead of the contraceptive patch. There are some contraceptive options where periods are extremely light or do not occur at all. These include the contraceptive implant, the intrauterine system, and contraceptive injections.