Patch and ring make inroads on birth control pill’s popularity

New birth control options give women expanded contraceptive choices

As you review the list of contraceptive options available at your family planning facility with your next female patient, which one most likely will receive the nod from her?

According to respondents to the 2005 Contraceptive Technology Update Contraception Survey, more women are choosing the transdermal contraceptive (Ortho Evra, Ortho-McNeil Pharmaceutical, Raritan, NJ) and the contraceptive vaginal ring (NuvaRing, Organon, West Orange, NJ).

The growth in use of these methods has come at the expense of the Pill’s popularity. In 2000, almost half of CTU survey participants said 50% or more of their patients left the office with oral contraceptive (OC) prescriptions in hand. In 2005, 37% of participants reported similar levels of Pill usage; about 33% say 26%-50% of patients are pill users.

"I think the number of OC users has declined in the last year," reports Marlene Michalowski, OGNP, a nurse practitioner at the Planned Parenthood of Northern Michigan in Mount Pleasant. "We still have more than 50% OC users, but many, many clients are using the NuvaRing."

Almost 93% of 2005 survey participants say their facility offers the transdermal contraceptive, while 76% report use of the contraceptive vaginal ring. Both methods show slight gains over 2004’s respective figures of 91% and 72%.

Ring draws interest

NuvaRing releases a continuous low dose of the estrogen ethinyl estradiol and the progestin etonogestrel at an average rate of 0.120 mg etonogestrel and 0.015 mg ethinyl estradiol per day over a 21-day period of use.

The contraceptive vaginal ring has become extremely popular at Planned Parenthood of Northern Michigan in Traverse City, says Patty Bauer, MSN, RNC, a nurse practitioner.

"The teenagers have really appreciated this method; there is lots of word of mouth convincing others to try it," she says. "I think it’s the best thing since sliced bread."

Side effects often may impact success with a chosen method. Results of a pharmacokinetic comparison of ethinyl estradiol released from the transdermal patch, an oral contraceptive, and the NuvaRing suggest that estrogen exposure with the ring is 3.4 times lower than observed with the patch and 2.1 times lower than observed with the oral contraceptive.1

The study evaluated multiple measurements of ethinyl estradiol serum levels in women randomly assigned to use the ring, the patch, or a 30 mcg pill. Women using the ring had a lower fluctuation in serum estrogen levels than with the other methods; women using the Pill had the highest degree of variation in serum concentrations. Women who used the patch reported a higher incidence of estrogen-related side effects, including nausea and breast tenderness, than those in the pill and ring groups.1

A study examining the number of patient callbacks in the first three months after the initiation of vaginal rings, transdermal patches, or oral contraceptives reports that ring users generated the least amount of callbacks.2 Women participating in the study selected the contraceptive methods of their choice; all patients were given standard counseling and reference handouts. Participants had never used or had discontinued hormonal contraception for at least one month prior to the study.2

Evra often is selected by younger women who have read about it and want to try it, says Martha Kleinerman, RNC, MS, health services director at the Planned Parenthood League of Massachusetts in Boston.

Each transdermal patch contains 20 mcg of the estrogen ethinyl estradiol and 150 mcg of the progestin norelgestromin, the primary active metabolite of norgestimate. The patch is designed to be changed once a week and worn for three weeks followed by one patch-free week. It consists of an adhesive medicated layer worn against the skin, protected by a waterproof polyester layer.

Patients on Ortho Evra generally love it and continue with it, reports Julia McAndrew, NP, a nurse practitioner at the Cattaraugus County Health Department Family Planning Clinic in Olean, NY. Patient complaints center on adhesive problems with the patch itself, either in difficulty in removing or difficulty in keeping it adhered, she says.

To apply the patch, women should press down firmly on the patch with the palm of the hand for 10 seconds and make sure that the edges stick well. To be certain adhesion is secure, instruct patients to run their finger around the edge of the patch.3

Baby oil removes the patch’s adhesive and can help lift it off if it gets stuck, says Anita Nelson, MD, professor in the obstetrics and gynecology department at the University of California in Los Angeles (UCLA) and medical director of the women’s health care programs at Harbor-UCLA Medical Center in Torrance.

Clinicians have been fielding questions about the patch’s safety after a media report claimed that the death rate for the method is three times that expected for oral contraceptives. Remember that the same precautions and danger signals for combined oral contraceptives apply to the patch and the ring. Use the "ACHES" mnemonic (abdominal pain, chest pain, headaches that are severe, eye problems, severe leg pain) to teach women these danger signals.4

With the advent of extended or continuous regimens of oral contraceptives, researchers also are examining the potential use of such regimens for the transdermal contraceptive and the contraceptive vaginal ring.5,6 Neither Ortho Evra nor NuvaRing has received Food and Drug Administration approval for such extended use.


  1. van den Heuvel MW, van Bragt AJM, Alnabawy A, et al. Comparison of ethinyl estradiol pharmacokinetics in three hormonal contraceptive formulations: The vaginal ring, the transdermal patch, and an oral contraceptive. Contraception 2005; 72:168-174.
  2. Victor IL, Fink RA. Comparing patient telephone callback rates for different hormonal birth control delivery systems. Presented at the 42nd annual meeting of the Association of Reproductive Health Professionals. Tampa/St. Petersburg, FL; September 2005.
  3. Moore A, Clark B. The transdermal contraceptive system: A unique look at patch users. Female Patient 2004; 29:7-11.
  4. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 18th revised ed. New York City: Ardent Media; 2004.
  5. Stewart FH, Kaunitz AM, LaGuardia KD, et al. Extended use of transdermal norelgestromin/ethinyl estradiol: A randomized trial. Obstet Gynecol 2005; 105:1,389-1,396.
  6. Miller L, Verhoeven CH, Hout JI. Extended regimens of the contraceptive vaginal ring: A randomized trial. Obstet Gynecol 2005; 106:473-482.