Patch and Ring Errors
Patch and ring errors are a late start of a cycle, a late change or removal, early detachment or expulsion, and wear beyond the intended period. The risk arises when hormone levels fall during a lengthened hormone-free period and ovulation escapes. The error rules depend on the week of the cycle and on whether the delay is 48 hours or less, or more than 48 hours.
Patch. Norelgestromin 6 mg with ethinylestradiol 0.6 mg, releasing about 150 and 35 micrograms daily, changed weekly for 3 weeks with 1 patch-free week. The patch change may be up to 48 hours late without backup.
Ring. Etonogestrel 11.7 mg with ethinylestradiol 2.7 mg, releasing about 120 and 15 micrograms daily, in place for 3 weeks with 1 ring-free week. A ring out for up to 48 hours or inserted up to 48 hours late needs no backup.
Risk. Pregnancy risk is greatest when a new patch or ring is started late. First-year pregnancies: 8 in 100 women with typical use and 0.3 in 100 with perfect use.
Return to fertility. Without delay after stopping.
Assessment. Establish the week of the cycle, the length of the delay in hours, and the date and number of episodes of unprotected sex in the last 5 days. Ask when the patch was last known to be in place, whether the ring was out during sex or cleaning, and about medicines.
Pregnancy test. Test when the patch or ring has been off or out for more than 48 hours in week 1, when the ring-free interval was 10 days or more, or when withdrawal bleeding fails to occur. Repeat the test after 2 weeks if unprotected sex occurred more recently.
Eligibility. Errors do not change eligibility. Category 3 and 4 conditions remain contraindications: breastfeeding under 6 months, blood pressure 140/90 or more, migraine with aura, current or past venous thrombosis, stroke, ischaemic heart disease, breast cancer, smoker 35 years or more with 15 or more cigarettes daily, rifampicin or rifabutin, and enzyme-inducing antiseizure medicines.
Patch-specific factors. Weight of 90 kg or more reduces efficacy; skin disease, heat, sweat and adhesive allergy increase detachment.
Ring-specific factors. Expulsion is more likely with constipation, straining, prolapse and tampon removal.
Counselling points for the clinician. Link the change day to a fixed weekly routine and set reminders. Teach patients to check the patch edges daily and to feel for the ring after bowel movements and intercourse. Offer condoms and advance supply of emergency contraception. Consent, no coercion, assent from under 18 years.
Special groups. Adolescents: offer support with reminders and consider a long-acting method. Postpartum and breastfeeding: not before 21 days if not breastfeeding; from 6 months if breastfeeding. Patients with weight of 90 kg or more: replace the patch with another method.
Patch regimen line. Norelgestromin 6 mg with ethinylestradiol 0.6 mg, transdermal, one patch weekly for 3 weeks then 1 patch-free week, applied to the upper outer arm, back, abdomen or buttock but never the breasts. Grace: 48 hours late. The patch-free week never exceeds 7 days. Backup 7 days after late application beyond 48 hours. Enzyme inducers: do not use. Weight of 90 kg or more: another method is preferred.
Ring regimen line. Etonogestrel 11.7 mg with ethinylestradiol 2.7 mg, vaginal, in place 3 weeks then 1 week out. Grace: 48 hours late or out. Backup 7 days after errors beyond 48 hours. Enzyme inducers: do not use.
Patch rules.
| Situation | Action |
|---|---|
| New patch not applied after the patch-free week, 48 hours or less late | Apply now; keep the same patch-change day; no backup |
| New patch not applied after the patch-free week, more than 48 hours late (no patch for 10 days or more) | Apply now; keep the same day; backup 7 days; consider emergency contraception if sex in the last 5 days |
| Patch change at end of week 1 or 2, 48 hours or less late | Apply a new patch now; keep the same day; no backup |
| Patch change at end of week 1 or 2, more than 48 hours late | Apply a new patch now; this starts a new 4 week cycle and a new patch-change day; backup 7 days; consider emergency contraception if sex in the last 5 days |
| Removal at end of week 3 late | Remove it; start the next cycle on the usual day; no backup |
| Patch off for 48 hours or less | Reapply (the same patch if off under 24 hours, otherwise a new patch); keep the same day; no backup |
| Patch off for more than 48 hours, or unknown time off | Apply a new patch now; keep the same day; backup 7 days; in week 3 skip the patch-free week and start a new patch straight away; in week 1 consider emergency contraception if sex in the last 5 days |
| Patch partly detached | Press firmly; if it does not stay, replace it with a new patch; do not use tape or wraps |
Ring rules.
| Situation | Action |
|---|---|
| Ring out for 48 hours or less in weeks 1 to 3 | Rinse in clean water and reinsert now; no backup |
| Ring out for more than 48 hours in week 1 or 2 | Reinsert now; backup 7 days; consider emergency contraception if sex in the last 5 days and the lapse was in week 1 |
| Ring out for more than 48 hours in week 3 | Reinsert now; backup 7 days; start a new ring at the end of week 3 and skip the ring-free week; if that is not possible, use backup until 7 days after the new ring |
| New ring not inserted at the start of the cycle, 48 hours or less late (ring-free interval no more than 9 days) | Insert now; keep the same removal day; no backup |
| New ring inserted more than 48 hours late (ring-free interval 10 days or more) | Insert now; backup 7 days; consider emergency contraception if sex in the last 5 days |
| Ring left in up to 28 days | No backup; take the ring-free week or insert a new ring at once |
| Ring left in 28 to 35 days | Insert a new ring and skip the ring-free week; no backup |
| Ring left in more than 35 days | Exclude pregnancy, insert a new ring, backup 7 days |
Emergency contraception.
- Levonorgestrel 1.5 mg orally as a single dose (two 750 microgram tablets together is preferred) as soon as possible within 120 hours; a split dose of 750 micrograms twice, 12 hours apart, is acceptable. No renal or liver adjustment. Compatible with breastfeeding. Not needed if pregnant. Repeat if vomiting within 2 hours.
- Ulipristal acetate 30 mg orally as a single dose within 120 hours, where available. Avoid in severe liver disease. Wait 5 days before restarting hormonal contraception and use backup for 7 days afterwards.
- Copper intrauterine device within 5 days of unprotected sex: the most effective option.
- Levonorgestrel is less effective at body mass index of 30 or more; ulipristal or the copper device is preferred.
- After levonorgestrel, continue the patch or ring at once with backup for 7 days.
Follow up. Review in 3 weeks or at the next expected withdrawal bleed. Test for pregnancy if bleeding is absent. Offer a change of method after repeated errors.
Expected effects. Breakthrough bleeding, early or absent withdrawal bleeding, and for patch users skin irritation at the site; for ring users vaginal discharge, irritation and a foreign body sensation.
Pregnancy after errors. Stop the method and confirm the pregnancy and its location. Combined hormones are not known to harm the foetus. Pain or bleeding needs assessment for ectopic pregnancy.
Skin reaction. Rotate sites and keep skin dry; change method if severe or if detachment recurs.
Vaginitis. Identify and treat the infection; the ring may stay in place.
Unscheduled bleeding. Exclude pregnancy, infection and interacting medicines. Ibuprofen 800 mg orally three times daily for 5 days with food gives short-term relief (maximum 2.4 g daily; avoid in renal impairment, active peptic ulcer or significant liver disease; not used in pregnancy).
Red flags. Severe abdominal pain, chest pain or breathlessness, severe or new headache, eye problems and severe calf pain. Remove the patch or ring and arrange urgent evaluation.
When to change method. Repeated lapses, recurrent detachment or expulsion, weight of 90 kg or more with the patch, enzyme-inducing medicines, or a category 4 condition.
Referral and escalation. Suspected ectopic pregnancy or thrombosis needs emergency transfer. A ring that cannot be removed or is lost in the vagina needs examination by a clinician. Offer an intrauterine device or implant after repeated failures.
