Evra: what it is used for, dosage and side effects
Evra is a combined hormonal contraceptive patch with two active substances: norelgestromin and ethinylestradiol. It is stuck to the skin and releases both hormones steadily, so there is no daily tablet. It is prescription only, because it carries the same class of risk as other combined hormonal contraception and a doctor has to weigh up blood pressure, the risk of blood clots and everything else you take. This page explains how it works, what a doctor checks, what to do when a patch comes off, and what we can and cannot do about a prescription.
What Evra is and which active substances it contains
Evra is a thin patch that releases two active substances through the skin: norelgestromin, a progestogen, and ethinylestradiol, an oestrogen. Because it contains both, it belongs to the combined hormonal contraceptives, in the same class of risk as the combined pill and the vaginal ring.
In the European Medicines Agency data for the Maltese market it is listed with the active substances ethinylestradiol and norelgestromin and the route of administration: transdermal, that is through the skin. The route is what patients notice: the hormones do not pass through the stomach, so a stomach upset does not affect absorption.
The form changes the routine, not the class. Everything that applies to combined contraception in terms of the risk of clots and the situations in which it is unsuitable applies here too. The combined pill is described on /medicines/yasmin/ and the vaginal ring on /medicines/nuvaring/, with an overview of the group in /contraceptive-pill/.
The exact composition, the release rate and the storage rules are in the patient information leaflet in your pack. The list of medicines authorised in Malta is kept by the Medicines Authority, the body that authorises medicines here and monitors their safety.
What it is used for
The authorised use is contraception in women who choose a combined hormonal method in this form. Used as directed it is a reliable method, but no method is absolutely certain, and reliability in practice depends on using it as the leaflet says.
The form suits people for whom remembering a daily tablet is the weak point of the method, and it removes the effect of vomiting or diarrhoea on absorption. It does not suit everyone: the patch has to stay stuck, it is visible on the skin, and skin that reacts to adhesives is a practical reason to choose something else.
It does not protect against sexually transmitted infections. Only barrier methods do that, and they can be used alongside it.
It is not emergency contraception and does not replace it. If a risk of pregnancy has already occurred, the route is different and the timing of what you do matters.
How it works and how the patch is used
The two substances act together as in other combined methods: they suppress the release of an egg from the ovary, change the mucus at the entrance to the womb and change the lining of the womb. Suppressing ovulation is the main mechanism, and it depends on a steady level of both hormones.
The patch is changed on a weekly rhythm within each cycle, and each cycle includes an interval without a patch, during which a withdrawal bleed usually occurs. The exact schedule, including which day of the week you change it and how long the patch-free interval lasts, is in the patient information leaflet for your pack and in the instruction from the doctor who prescribed it. We do not restate those intervals here, because they belong to the pack you hold.
The patch goes on clean, dry, intact skin that is not oiled or creamed, and on a site the leaflet allows; the breast is not one of them. Change the site each time to reduce skin irritation, and press the patch down firmly for a short while so that the edges stick. Do not cut a patch and do not use one that has lost its stickiness.
A withdrawal bleed in the patch-free interval is not the same as a natural period. Its absence does not automatically mean pregnancy, but it is a reason to check, especially if a patch was off for longer than the leaflet allows.
If a patch comes off or is changed late
A patch can lift at the edges or come off completely, most often with sweating, in water or where it was applied to skin that was not quite dry. The leaflet for your pack sets out what to do, and the answer depends on how long it was off and where in the cycle that happened.
A short interruption is usually dealt with by sticking the same patch back on, or applying a new one if it no longer sticks, while a longer one can mean that protection has been reduced and that additional protection is needed. Read that section of the leaflet before it happens, because you will not want to be working it out under pressure. The same principle of acting on the interval is explained for tablets in /health-guide/missed-contraceptive-pill/.
Do not tape or bandage a patch to keep it in place, and do not apply a second patch on top of one that has lifted. If you are unsure how long a patch was off, treat the situation as the less favourable case and use additional protection until you can check with a doctor or a pharmacist.
A change made late, at the end of the patch-free interval, is treated differently from one made late in the middle of a cycle. If a risk of pregnancy has occurred, consider whether emergency contraception is needed; the sooner that decision is made, the better.
The risk of blood clots and what the doctor assesses
Combined hormonal contraception raises the risk of venous thromboembolism, that is a clot in a vein, most often in the leg, which can travel to the lungs. In absolute terms the risk is small in healthy young women, but it is real, and it is the reason this method is prescription only in every form it comes in.
The risk is higher in the first months after starting or restarting, after a long period without hormonal contraception, in smokers, with rising age, with obesity, after childbirth, after major surgery or long immobility, and where there is a personal or family history of clots or a known clotting disorder. Migraine with aura, uncontrolled high blood pressure and some diseases of the liver, heart or blood vessels make combined contraception unsuitable, not merely something to be careful about.
That is what a doctor weighs up before prescribing, together with blood pressure, which is why a recent blood pressure reading is a reasonable thing to have to hand. Where combined contraception is not suitable, a progestogen only method may be, and that is a conversation to have with a doctor.
The warning signs are worth knowing: swelling, pain or heat in one calf; sudden breathlessness or chest pain; coughing up blood; sudden severe headache with disturbed vision or speech, weakness or numbness on one side. Seek urgent medical help, and in an emergency in Malta call 112.
Interactions and side effects
Some medicines speed up the breakdown of the hormones in the liver and can make contraception less reliable: certain medicines used in epilepsy, certain medicines used in tuberculosis, some antiretrovirals and the herbal preparation St John's wort, which is sold without a prescription. A complete list of what you take therefore belongs in the assessment, supplements and herbal products included.
Because absorption does not pass through the stomach, vomiting and diarrhoea do not affect this method. Creams, oils and powders on the skin where the patch goes do affect it, so that area is left bare.
The side effects described most often are headache, nausea, breast tenderness, skin reactions at the patch site, mood changes, spotting between periods and reduced desire. Skin reactions are the complaint most specific to this form, and changing the site each time helps. Spotting is most common in the first months and usually settles.
Serious events are much rarer but they are the reason for the prescription requirement: clots in veins or arteries, serious liver disorders and cardiovascular events where blood pressure is uncontrolled. A new migraine, or one that becomes different or comes with aura, is a reason to contact a doctor promptly. How often each effect occurs is in the leaflet for your pack.
Prescription status and what we can do
Evra is prescription only, so a pharmacy does not supply it without a prescription. The decision to prescribe belongs to a doctor after an assessment of your medical information, which for combined contraception includes blood pressure and the risk of clots. We do not sell medicines and we do not ship them; our service is a medical assessment and the issuing of a document.
Whether contraception is covered by the public health service in Malta, and on what terms, is decided by the health authorities and not by us. Our service is private and is not covered by them, so the pharmacy price of the pack and our fee are two separate items. A pharmacy will tell you the current price.
Our model is a medical questionnaire that a doctor reviews asynchronously, from your answers and any records you attach. There is no video call, no phone call and no live chat with a doctor. If this method has already been started by a doctor and this is a continuation, you can ask for an assessment at /contraception/ for 24,90 €. Priority handling is available for an extra 9,90 €, which is not a promise of a deadline. A first start, a change of method or new symptoms need a doctor who can examine you.
If the doctor issues a prescription, you receive the document by email as a PDF in the standard EU cross-border format set out in Directive 2012/52/EU; its recognition in another member state is governed by Directive 2011/24/EU. There is no code and the document is not entered in any Maltese state health record, so you go to the pharmacy with a printout or with the PDF on screen, together with photo identification. A pharmacy in Malta may dispense it; the decision rests with the pharmacist, who can refuse, for example where the pack is not available locally. What a pharmacy checks is explained in /blog/eu-prescription-maltese-pharmacy/. The fee covers the doctor's assessment, not the issuing of a document. If the doctor declines on medical or legal grounds, we refund the fee. If we ask you for medical records, you have at least 7 days to reply. We then send a reminder and extend the deadline on request, and where the assessment still cannot be completed we close the request and refund the fee. The assessment is carried out by Damian Wojno, a doctor registered in Poland, licence no. 3211301, MEDINOW Sp. z o.o. He is not registered with the Medical Council of Malta, which keeps the register of doctors practising here.
Is Evra prescription only in Malta?
Yes. It is supplied on prescription only, because it is combined hormonal contraception and carries the same class of risk as the combined pill. A doctor has to weigh up blood pressure, your history and everything else you take before it is started. A pharmacy will not supply it without a prescription, and an assessment can end in a refusal or in a recommendation of a different method.
How often is the patch changed?
On a weekly rhythm within each cycle, with an interval at the end of the cycle when no patch is worn. The exact schedule, including the change day and the length of the patch-free interval, is in the patient information leaflet for your own pack. Follow that rather than general advice, because the schedules of different products are not interchangeable.
Which side effects are common?
Headache, nausea, breast tenderness, skin reactions where the patch sits, mood changes, spotting between periods and reduced desire are the most commonly described. Changing the site each time reduces skin irritation. Warning signs of a clot, such as pain or swelling in one calf, sudden breathlessness, chest pain or a sudden severe headache with disturbed vision, mean urgent medical help.
What happens if a patch comes off?
What matters is how long it was off and where in the cycle that happened. A short interruption is usually handled by sticking the same patch back on, or applying a new one if it no longer sticks; a longer one can mean reduced protection and a need for additional protection. Follow the leaflet for your own pack, and if you are unsure, treat it as the less favourable case.
Can I swim, shower and use a sauna with it?
Water itself is not the problem and normal washing is expected, but heat, prolonged soaking and rubbing all work against the adhesive, so check the edges afterwards. Do not use creams, oils or powders on the area where the patch goes. If the patch will no longer stick properly, follow the leaflet rather than trying to hold it in place with tape.
How is a repeat prescription arranged?
If a doctor has already started this method and you are continuing with it, fill in the medical questionnaire at /contraception/. The medical assessment costs 24,90 €. A recent blood pressure reading is worth having to hand, because for combined contraception it is part of the assessment. We do not promise a deadline, because it depends on the completeness of your answers and on the doctor's assessment.