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Hormonal Contraceptive methods Under Supervision by Dr. Magda Ahmad ‫‪Prepared by‬‬ ‫محمود محمد عشماوى على الحصرى‬ ‫نورهان ياسر عيد يادم‬ ‫نورهان محمد حلمى قديحه‬ ‫نورهان محمد محمود عبد الحميد جاد‬ ‫نورهان محمد محمود محمد‬...

Hormonal Contraceptive methods Under Supervision by Dr. Magda Ahmad ‫‪Prepared by‬‬ ‫محمود محمد عشماوى على الحصرى‬ ‫نورهان ياسر عيد يادم‬ ‫نورهان محمد حلمى قديحه‬ ‫نورهان محمد محمود عبد الحميد جاد‬ ‫نورهان محمد محمود محمد‬ ‫نيره ابوزيد عبد الجواد كامل حوطر‬ ‫هاجر ابراهيم صبرى الشاطر‬ ‫يوسف سالمه خميس‬ Outlines Definition Types -Oral (combined pills, mini pillis -Injection. -Implants. -Vaginal ring. -Contraceptive patch. Avaliabilty Mechanism of Action Safty and effetivness Indication and contraindication Advantages and disadvantages Side effect and complication Technical aspect and counsling Definition of Hormonal contraceptive methods Hormonal contraceptive methods are forms of birth control that use hormones to prevent pregnancy. Types of Homonal methods Types: -Oral (combined pills, mini pillis -Injection. -Implants. -Vaginal ring. -Contraceptive patch. Types of Hermonal Contraceptive  Contraceptive Pills Definition of pills: Contraceptive pills, also known as birth control pills, are oral medications specifically designed to prevent pregnancy.  Mechanism of action of Contraceptive pills Inhibition of Ovulation: The estrogen and progestin in COCs work together to suppress the body's natural hormonal fluctuations, particularly the surge of luteinizing hormone (LH) that triggers ovulation. By inhibiting ovulation, there is no egg released for fertilization. Thickening of Cervical Mucus: COCs also thicken the cervical mucus, making it difficult for sperm to reach the egg.  Method of use Contraceptive pills Start on the Correct Day: Begin taking your contraceptive pills on the first day of your menstrual cycle for immediate protection. If you start on a different day, additional contraceptive methods may be needed for the first cycle.  Method of use Contraceptive pills  Understand Missed Pill Protocols: If you miss a pill or take one late, refer to the instructions in your pill pack or consult your healthcare provider on the appropriate course of action. Additional contraceptive measures, like condoms, may be recommended depending on the timing of the missed pill  Advantage 1. High Effectiveness: When taken correctly and consistently, contraceptive pills are highly effective at preventing pregnancy. They offer a reliable form of contraception, with a typical effectiveness rate of over 90% when used as directed  Advantage 2. Regulation of Menstrual Cycles: Contraceptive pills can help regulate menstrual cycles, making periods more predictable and reducing symptoms like irregular bleeding, cramps, and heavy flow. Some formulations can also be used to treat conditions like polycystic ovary syndrome (PCOS). 3. Reduced Menstrual Symptoms: Many individuals experience a reduction in menstrual symptoms like cramps, bloating, and mood swings when using contraceptive pills. Some formulations can even help  Disadvantages of Contraceptive pills 1. Side Effects: Some individuals may experience side effects when taking contraceptive pills, such as nausea, breast tenderness, headaches, mood changes, or spotting between periods. These side effects are usually mild and tend to improve after a few months of use. However, if side effects persist or become severe, it's advisable to consult a healthcare provider. 2. Health Risks: Certain individuals may be at an increased risk of developing health complications while taking contraceptive pills. Factors such as smoking, age, family history of blood clots or cardiovascular issues, and existing medical conditions can  Disadvantages 3. No Protection Against STIs: While contraceptive pills are highly effective at preventing pregnancy, they do not offer protection against sexually transmitted infections (STIs). It's essential to use condoms or other barrier methods in conjunction with contraceptive pills to reduce the risk of STI transmission. 4. Consistency and Timing: Contraceptive pills require consistency in dosing and timing to maintain their effectiveness. Missing pills or taking them at irregular intervals can decrease contraceptive efficacy and increase the risk of unintended pregnancy. Establishing a routine and  Side effects and complications 1. Nausea: Some individuals may experience mild nausea, especially when starting a new type of contraceptive pill. Taking the pill with food or at bedtime can help alleviate this symptom. 2. Breast Tenderness: Hormonal changes from contraceptive pills can lead to breast tenderness or enlargement for some individuals. This side effect typically improves after a few months of pill use 3. Headaches: Hormonal fluctuations may trigger headaches in some individuals using contraceptive pills. If headaches become severe or persistent, it's advisable to consult a healthcare provider. 4. Spotting or Irregular Bleeding: Light spotting between periods or irregular bleeding may occur, particularly during the first few months of starting a new  Technical aspects and counseling. Dosage and Timing: Contraceptive pills should be taken at the same time each day to maintain their effectiveness. Missing pills or taking them at irregular intervals can increase the risk of unintended pregnancy. Follow the instructions provided with your pill pack or consult a healthcare provider for guidance. 3. Storage and Handling: Store contraceptive pills in a cool, dry place away from direct sunlight and moisture. Check the expiration date on the pill  Technical aspects and counseling Alternative Contraceptive Options: If contraceptive pills are not suitable or preferred, healthcare providers can discuss alternative contraceptive methods, such as hormonal injections, implants, or intrauterine devices (IUDs), based on your needs and preferences.  contraceptive injection (Depo What is the contraceptive injection (Depo)? The contraceptive injection (also called Depo) is an injection of the hormone progestogen. Progestogen is similar to the hormone produced by the ovaries. The contraceptive injection is sold as Depo-Provera or Depo-Ralovera in Australia. Injection root How effective is the injection? Each injection is more than 99% effective at preventing pregnancy and lasts for 12 – 14 weeks. If you have a late injection, it might only be 96% effective. ٢) How does the injection work? The injection works by preventing the ovaries from releasing an egg each month. It also thickens the fluid around the cervix (opening to the uterus/womb). This helps to prevent sperm from entering. How do I use the injection? Depo is injected by a doctor or nurse into the arm or bottom muscle every 12-14 weeks. When does it start to be effective? When Depo is first injected, or after a break, it can take up to 7 days to start working to prevent pregnancy. This depends on the timing of your menstrual cycle and if you are already using contraception. Speak with your doctor, nurse or pharmacist for more information. Where can I get the injection? Your doctor or nurse will provide a script which you can take to the pharmacy, who will sell you the Depo. You will need to return to the clinic to have the Depo injected. It will be cheaper if you have a healthcare card. What stops the injection from working? The injection might not work if you are late having your injection. What is good about the injection? It is very effective. What is good about the injection? It is very effective. It lasts for 12 – 14 weeks. Most users have no vaginal bleeding (period) at all or very light bleeding. Periods may be less painful. You can use it while breast feeding. No medications stop it from working. Are there any side effects from using the injection? Your vaginal bleeding pattern (period) will change. It might be more often and/or irregular (at odd times). Around 50 – 60% of people using the injection will have no bleeding at all (this is not harmful to the body). Frequent or prolonged bleeding may get better with time. Some medications can help with this bleeding, speak to your doctor or nurse for Around 20% of users will gain weight. There is a small drop in your bone density (your bones become thinner). This is not thought to be harmful for most people, as your bone density returns once you stop the injections. Other possible side effects for a small number of users can include: headaches changes to your skin sore/ tender breasts Can the injection cause any serious health problems? There are no known serious health risks from having the contraceptive injection Reasons why the injection might not be a good option for you: It is difficult to see a doctor or nurse every 12 – 14 to have the injection. You have plans to become pregnant in the near future. Have breast cancer or have been treated for breast cancer. Have severe liver disease. Have a number of risk factors for heart disease (e.g. smoking, diabetes). Had a previous heart attack or a stroke. What if I am late having the injection? If you do not want to become pregnant and it is more than 14 weeks since your last injection, you can abstain from sex or use condoms until you can have your next injection. It can take up to 7 days for Depo to start working to prevent pregnancy. During this time, you can continue to abstain from sex or use condoms. If you have unprotected sex in the time when your Depo is late or not effective, you might need emergency contraception. ١ Pros and Cons of Birth Control Shots Although birth control shots have proven to be a reliable and convenient form of preventing pregnancy for thousands of women, they may not be the right fit for everyone. Birth Control Shots Pros  The shots are more than 99% effective with perfect use and 94% effective with typical use.4 The shots require only four applications per year, making it easy for women to be compliant. The shots can be used by women who cannot or do not want to take estrogen. Many women have lighter periods while on birth control shots. After a year, most women stop having periods all together. Contraceptive injections do not prevent sexually transmitted infections (STDs). It may take up to 10 months for a woman's menstrual cycle and fertility to return after stopping the shots.4 The out-of-pocket cost can be as high as $150 per visit, in addition to doctor's visit fees. Studies linked birth control shots to a potentially higher risk of breast cancer in women younger than 35.5 Long-term use of injectable contraception may affect the amount of calcium in the bones.6 IMPLANT  IMPLANT -Definition Is a small, flexible, thin rod like device inserted under the skin in the arm to prevent pregnancy by release the hormone norgesteral in to the blood stream. Availability It's a tiny, thin rod at the shape of matchsticks.  - Mechanism of action The implant release a slow,steady dose of norgesteral in the body. Norgesteral prevent the ovary from releasing an egg (ovulation). It thicken the mucus in the cervix which make it hard for sperm to reach the egg. Norgesteral also thinks the uterine lining, making it difficult for a fertilized egg to implant. -Safty and Effectiveness Hormonal implant works more than 99% of the time. It can use for up to 3 years, then you need to get it replaced. - Indication Can be used for the women that contraindicated for oral contraceptive pills. Breast feeding. Effective women of all body mass. - Contraindication Unexplained vaginal bleeding. Breast cancer. Pregnancy. Liver disease or Liver tumors. History of blood clots. Over weight. Advantage ofContraceptive implants  - Advantage It's currently approved for three years but effective for up to five years. It safe for people who can't use estrogen containing birth control. You can use it while you're breast feeding (chest feeding). It can reduce heavy menstrual bleeding.  - Disadvantage The provider has to inserted it in to their office. It makes acne worse. It doesn't offer any protection against sexual transmitted infections (STIs). It may interfer with certain medications and antibiotics. Pros and cons of Contraceptive implants  - Side effects and Complications Possible side effect include problems from putting it: Pain, Bruising, swelling, redness, infections, scarring. Other Complications: Irregular menstrual bleeding. Abdominal pain and nausea. Weight gain. - Technical aspects Time of insertion at first day of the menstrual bleeding. The women received an injection of local anesthetic under skin. An incision is made on the inside of the upper arm. The provider inserts the capsules just under the skin.  - Counseling The women shouldn't use this arm in vigorous movements. She should keep the area of insertion dry. The doctor is the only person responsible for insert the implant in the women arm. Implant need to removal after 3-5 years.  Vaginal ring The definition of the vaginal ring is a flexible, transparent ring used as a form of hormonal contraception. It is inserted into the vagina, where it releases hormones (typically estrogen and progestin) to prevent ovulation, thicken cervical mucus, and thin the uterine lining. Availability 1. Prescription Requirement: In most countries, the vaginal ring is available only with a prescription. This means you will need to consult with a healthcare provider who can evaluate your medical history and determine if it's a suitable contraceptive option for you. 2. Pharmacies: Once you have a prescription, you can typically obtain the vaginal ring at local pharmacies. Some pharmacies may also offer online services where you can order it after an online consultation. 3. Insurance Coverage: Many health insurance plans cover the cost of the vaginal ring, but coverage can vary. It's advisable to check with your insurance provider regarding coverage and any associated costs. 4. Generic Options: There may be generic versions of the vaginal ring available, which can be more affordable than brand-name options. 5. Availability in Different Countries: The specific brand and formulation of the vaginal ring may differ by country. For example, NuvaRing is widely available in the United States and many other countries, but similar products might have different names or formulations elsewhere. 6. Consultation Services: Some telehealth services offer consultations for contraceptive options, including the vaginal ring, allowing you to receive a prescription remotely. If you're considering using a vaginal ring, it's best to consult with a healthcare provider who can provide personalized advice and information about availability in your area. ▎Mechanism of Action 1. Inhibition of Ovulation: - The primary mechanism by which the vaginal ring prevents pregnancy is by inhibiting ovulation. The hormones released from the ring prevent the pituitary gland from releasing luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which are necessary for the maturation and release of an egg from the ovaries. 2. Thickening of Cervical Mucus: - The progestin component of the vaginal ring causes the cervical mucus to thicken. This makes it more difficult for sperm to travel through the cervix and reach any eggs that may have been released, thereby reducing the likelihood of fertilization. 3. Alteration of Uterine Lining: - The hormones also cause changes in the endometrial lining (the lining of the uterus). The lining becomes thinner, making it less receptive to a fertilized egg. If fertilization were to occur, a thinner lining would decrease the chances of implantation. 4. Local Effects: - The vaginal ring releases hormones locally, which can lead to lower systemic ▎Safety 1. General Safety: The vaginal ring is considered safe for most women. However, like all hormonal contraceptives, it may not be suitable for everyone. Women with certain health conditions, such as a history of blood clots, certain cancers, or uncontrolled hypertension, may be advised against using it. 2. Side Effects: Common side effects can include: - Nausea - Headaches - Breast tenderness - Mood changes - Vaginal irritation or discharge 3. Serious Risks: There is a small risk of serious side effects, including: - Venous thromboembolism (blood clots) - Stroke - Heart attack These risks may be higher for women who smoke, are over 35 years old, or have other risk factors. ▎Effectiveness 1. Pregnancy Prevention: When used correctly, the vaginal ring is about 91% to 99% effective at preventing pregnancy. It is important to insert and replace the ring according to the instructions for maximum effectiveness. 2. User Compliance: The effectiveness can be influenced by user compliance. The ring is typically worn for three weeks and then removed for one week during which menstruation occurs. It's crucial to follow these guidelines to maintain its contraceptive efficacy. 3. Additional Benefits: Beyond pregnancy prevention, the vaginal ring may also provide other benefits such as: - Regulation of menstrual cycles Contraindications of vaginal ring 1. History of Blood Clots: Women with a history of deep vein thrombosis (DVT), pulmonary embolism, or other thromboembolic disorders should avoid using the vaginal ring due to an increased risk of blood clots. 2. Certain Cardiovascular Conditions: Individuals with uncontrolled hypertension, certain heart conditions (such as severe heart valve disease or ischemic heart disease), or a history of stroke should not use the ring. 3. Active Liver Disease: Women with liver tumors or active liver disease that affects liver function should avoid hormonal contraceptives, including the vaginal ring. 4. Breast Cancer: A personal history of breast cancer or other hormone-sensitive cancers is a contraindication due to the hormones in the ring. 5. Undiagnosed Abnormal Vaginal Bleeding: Any unexplained vaginal bleeding should be evaluated before using the ring, as it may mask underlying conditions. 6. Migraine with Aura: Women who experience migraines with aura are at higher risk for stroke when using estrogen-containing contraceptives like the vaginal ring. 7. Severe Diabetes with Vascular Complications: Women with diabetes that has caused complications (such as retinopathy, nephropathy, or neuropathy) should consult their healthcare provider before using the ring. 8. Hypersensitivity: Known hypersensitivity to any components of the vaginal ring is a contraindication. Advantages ▎1. Convenience: - Once-a-Month Use: The vaginal ring is inserted once a month and remains in place for three weeks, making it easier to use compared to daily oral contraceptives. - Easy to Insert and Remove: Many users find it simple to insert and remove, which can be done in the privacy of their own home. ▎2. Effectiveness: - High Efficacy: When used correctly, the vaginal ring is highly effective at preventing pregnancy, with a failure rate similar to that of other hormonal methods. ▎3. Consistent Hormone Levels: - Steady Release of Hormones: The ring provides a steady release of hormones, which can lead to more stable hormone levels in the body and potentially fewer side effects compared to methods that cause more fluctuation. ▎4. Reduced Menstrual Symptoms: - Potential for Lighter Periods: Some users experience lighter menstrual bleeding and less painful periods while using the ring. - Menstrual Cycle Control: Users can have more predictable menstrual cycles, and some may even skip periods by managing the insertion schedule. ▎5. Non-Daily Method: - Less Daily Responsibility: Unlike the pill, which requires daily adherence, the ring only needs to be remembered once a month, reducing the chances of missed doses. ▎6. Local Hormonal Delivery: Disadvantages ▎1. Initial Insertion and Removal: - Learning Curve: Some users may find it uncomfortable or challenging to insert or remove the ring initially, which can be a barrier to effective use. ▎2. Possible Side Effects: - Hormonal Side Effects: Users may experience side effects similar to those associated with other hormonal contraceptives, such as nausea, headaches, breast tenderness, mood changes, or weight gain. - Vaginal Discomfort: Some individuals may experience vaginal irritation or discomfort while using the ring. ▎3. Risk of Expulsion: - Possibility of Displacement: The ring can sometimes be expelled from the vagina, particularly during activities like vigorous exercise or intercourse. If it is expelled, it must be reinserted within three hours to maintain contraceptive effectiveness. ▎4. Regular Replacement: - Monthly Schedule: Users need to remember to replace the ring every month, which can be a drawback for those who prefer a more long-term solution (e.g., IUDs or implants). ▎5. Potential for Increased Risk of Blood Clots: - Thromboembolic Risks: Like other combined hormonal contraceptives, the vaginal ring may increase the risk of blood clots, particularly in women who smoke, are over 35, or have other risk factors. ▎6. Cost and Accessibility: - Expense: Depending on insurance coverage and location, the cost of the vaginal ring may be higher than other contraceptive methods. - Prescription Requirement: The ring requires a prescription, which may limit access for some individuals compared to over-the-counter options. ▎7. Not Suitable for Everyone: Indications of vaginal ring 1. Contraception: The primary indication is to prevent pregnancy. The ring releases hormones (estrogen and progestin) that inhibit ovulation, thicken cervical mucus, and thin the uterine lining. 2. Menstrual Regulation: Some women may use the ring to help regulate menstrual cycles, making periods more predictable. 3. Management of Menstrual Symptoms: The ring can help alleviate symptoms associated with menstruation, such as heavy bleeding or severe menstrual cramps (dysmenorrhea). 4. Endometriosis: It may be used as part of the treatment plan for endometriosis to help reduce pain and manage symptoms. 5. Polycystic Ovary Syndrome (PCOS): The ring may help manage symptoms associated with PCOS, such as irregular periods or hormonal imbalances. 6. Hormonal Regulation: It can be used for women who need hormonal regulation for various reasons, including those with hormonal imbalances. Before using a vaginal ring, it’s important to consult with a healthcare provider to ensure it’s appropriate based on individual health conditions and needs. Side effects ▎Common Side Effects 1. Nausea: Some users may experience mild nausea, particularly when they first start using the ring. 2. Headaches: Hormonal fluctuations can lead to headaches or migraines in some individuals. 3. Breast Tenderness: Users might notice sensitivity or tenderness in their breasts. 4. Mood Changes: Hormonal contraceptives can affect mood and may lead to feelings of anxiety or depression in some individuals. 5. Weight Gain: Some users report weight gain, although this can vary widely among individuals. ▎Less Common Side Effects 1. Vaginal Discharge or Irritation: Some individuals may experience increased vaginal discharge or irritation due to the presence of the ring. 2. Breakthrough Bleeding: Spotting or breakthrough bleeding can occur, especially during the first few months of use. 3. Decreased Libido: Some users may notice a decrease in sexual desire. 4. Skin Reactions: Rarely, users may experience skin reactions such as rashes or irritation. ▎Serious Side Effects (Rare) 1. Blood Clots: There is a risk of developing blood clots (thromboembolism), particularly in women who smoke, are over 35, or have other risk factors. 2. Stroke or Heart Attack: The risk of serious cardiovascular events may be increased, especially in those with underlying health conditions. 3. Liver Tumors: Though rare, some hormonal contraceptives have been associated with liver tumors. 4. Severe Allergic Reactions: While uncommon, some individuals may experience severe allergic reactions, including difficulty breathing or swelling. ▎When to Seek Medical Attention If you experience any of the following symptoms, you should seek medical attention immediately: - Severe headache or migraine - Sudden vision changes - Chest pain or shortness of breath Complications 1. Local Reactions: Some users may experience irritation, discomfort, or infection in the vaginal area. 2. Hormonal Side Effects: Common side effects include nausea, headaches, breast tenderness, mood changes, and weight fluctuations due to hormonal changes. 3. Vascular Complications: There is a slightly increased risk of blood clots (venous thromboembolism), especially in women who smoke or have other risk factors. 4. Menstrual Changes: Some women may experience irregular bleeding or spotting, especially during the first few months of use. 5. Displacement: The ring can sometimes slip out of place or fall out, which may reduce its effectiveness. If this happens, it should be rinsed with cool water and reinserted as soon as possible. 6. Increased Risk of STIs: While the ring protects against pregnancy, it does not provide protection against sexually transmitted infections (STIs). 7. Potential for Hormonal Interactions: Certain medications can interact with the effectiveness of the ring, such as some anticonvulsants and antibiotics. 8. Serious Health Risks: In rare cases, serious complications such as stroke or heart ▎Technical Aspects of the Vaginal Ring 1. Composition: - The vaginal ring is typically made of a flexible, biocompatible polymer that allows for the release of hormones (usually etonogestrel and ethinyl estradiol). 2. Mechanism of Action: - Hormonal Release: The ring releases a steady dose of hormones over a 21-day period. - Preventing Ovulation: The hormones inhibit ovulation by suppressing gonadotropin release from the pituitary gland. - Cervical Mucus Thickening: Progestin thickens cervical mucus, making it difficult for sperm to enter the uterus. - Endometrial Changes: Alters the uterine lining, reducing the likelihood of implantation. 3. Insertion and Removal: - Insertion: Users can self-insert the ring. It should be placed deep enough in the vagina so that it stays in place. - Removal: After three weeks, the ring is removed for a one-week break during which withdrawal bleeding occurs. 4. Storage and Handling: - The ring should be stored in a cool, dry place. If it has been out of refrigeration for more than four months, it should not be used. 5. Effectiveness: - When used correctly, the vaginal ring is over 99% effective at preventing pregnancy. 6. Side Effects: - Common side effects may include nausea, headaches, mood changes, and vaginal discharge. Serious risks include blood clots, especially in smokers or those with other risk factors. ▎Counseling Points  Contraceptive patch Definition:The contraceptive patch is a hormonal method of birth control that applied to the skin and release estrogen and progestin to prevent pregnancy Mechanism of action :Just like most birth control pills, the patch contains a combination of the estrogen and progestin hormones. Whereas the hormones in the pill enter the bloodstream through the digestive system, the hormones in the skin patch are absorbed by the skin and enter the bloodstream in that way. These hormones work by preventing ovulation (the release of an egg from the ovaries), thickening cervical mucus to block sperm, and thinning the uterine lining to prevent Method of use : The contraceptive skin patch is about 5 cm by 5 cm in size, and very thin. It can be placed on the woman’s back,belly, the outside of her upper arm or anywhere on her upper body – with the exception of her breasts. It’s important to make sure that it sticks to the skin properly and doesn’t rub against clothing too much. Activities like having a shower, a bath or swimming usually don’t make it come off. In the first three weeks of the cycle, the patch is replaced once a week. No patch is used in the fourth week. The woman then gets her period. A new patch is stuck onto the skin seven days after removing the old patch. If it is stuck on 24 hours too late, it is no longer a reliable form of contraception Method of use : The contraceptive skin patch is about 5 cm by 5 cm in size, and very thin. It can be placed on the woman’s back,belly, the outside of her upper arm or anywhere on her upper body – with the exception of her breasts. It’s important to make sure that it sticks to the skin properly and doesn’t rub against clothing too much. Activities like having a shower, a bath or swimming usually don’t make it come off. In the first three weeks of the cycle, the patch is replaced once a week. No patch is used in the fourth week. The woman then gets her period. A new patch is stuck onto the skin seven days after removing the old patch. If it is stuck on 24 hours too late, it is no longer a reliable form of contraception Advantages : It’s convenient, as it only requires weekly attention, unlike daily pills. It can also help regulate periods and reduce menstrual cramps. Disadvantages:Some women may experience side effects such as nausea, headaches, or an increased risk of blood clots..it can cause skin irritation, itching and soreness (moving the location of the patch each week will help).It does not provide protection against sexually transmitted infections (STIs), including HIV. Less Common but Serious Complications: 1. Blood clots (venous thromboembolism): The patch contains estrogen, which can increase the risk of developing blood clots, leading to conditions like deep vein thrombosis (DVT) or pulmonary embolism. 2. Heart attack and stroke: Women who smoke and are over 35 years old are at a higher risk of cardiovascular events. 3. High blood pressure: Some women may develop elevated blood pressure while using the patch. 4. Liver problems: Rarely, the hormones in the patch can affect liver function. 5. Gallbladder disease: In some cases, hormonal contraceptives can increase the risk of gallbladder problems. Technical aspects and counseling: Application: The patch should be applied to clean, dry, and intact skin on the buttock, abdomen, upper outer arm, or upper back. It should not be applied to the breasts or irritated skin. Patch Change Schedule: The patch is worn for one week at a time. A new patch is applied each week for three consecutive weeks, followed by one patch-free week (week 4), during which withdrawal bleeding occurs. Effectiveness: Typical Use: About 91% effective. Perfect Use: Over 99% effective when used correctly. Considerations: Effectiveness may be lower in women over 198 pounds (90 kg), so alternative methods may be recommended in this case. Storage: Store the patch at room temperature, away from direct sunlight and moisture, and do not refrigerate it. Missed Patch: If a patch is detached for less than 48 hours: Reapply it or replace it