Meet Twirla—a new, lower dose patch

A new lower dose estrogen patch is now available!

by Robin Watkins, CNM, WHNP-BC

published 09/15/21

The FDA approval of Twirla means a new birth control patch option for your patients. With the addition of Twirla, there are now three patches available on the market—Twirla and two generics, Xulane and Zafemy. Twirla is a 1mm thick, beige, circular patch that contains a daily dose of 30 mcg of ethinyl estradiol and 120 mcg of levonorgestrel, making it the lowest dose estrogen patch available on the market. Xulane, Zafemy, and OrthoEvra (no longer available) contain a daily dose of 35mcg of estrogen and 150mcg of norelgestromin.

The basics of using Twirla

  • Each box of Twirla comes with three one-time use, transdermal patches.
  • Every week, on the same day each week, for three consecutive weeks, the old patch is removed and a new Twirla patch is placed on a clean and dry area of the abdomen, buttock, or upper torso (excluding the breasts). This is followed by a patch-free week before beginning with a new box of Twirla.
  • In clinical trials, Twirla was 95% effective in preventing pregnancy for people with a BMI <25. For people with a BMI of ≥ 25, Twirla may be less effective in preventing pregnancy.
  • Twirla is contraindicated for people with a BMI ≥ 30 due to decreased effectiveness as well as increased risk for venous thromboembolic events (VTE) .
  • Twirla, like other birth control patches, must adhere completely and securely to the skin to be effective in preventing pregnancy. If the edges of the patch lift up, patients can press down firmly to attempt to re-stick the patch. If the patch does not securely stick to the skin, the entire patch should be removed and replaced with a new patch. This starts a new four-week patch cycles (three weeks with a patch, one week without), changing the patch on the same (new) day of the week. If patients need a single, replacement patch, contact the manufacturer, they may be able to send it with no out-of-pocket costs.
  • If the patch, or part of the patch, has been off for more than one day (or they are unsure how long it has been), patients should use a backup method of birth control, such as condoms, for seven days after applying a new patch and starting a new four-week cycle.
  • In clinical trials, around 6% of users had a reaction where they applied Twirla.

Starting Twirla

Twirla can be quick started anytime you can be reasonably certain that someone isn’t pregnant. If Twirla is quick started after day five of the menstrual cycle, advise patients to use a backup method, such as condoms, or abstain for the first seven days of use.

Like other methods that contains estrogen (the ring, the combined birth control pill, or other patches), it may not be a good option for some people, such as those with high risk of arterial or venous thrombotic diseases; people with hypertension; those who are over 35 years old and smoke more than 15 cigarettes a day; those with current or history of breast cancer or other estrogen or progestin-sensitive cancer; and those with some types of liver tumors, acute hepatitis, or severe (decompensated) cirrhosis.

How to get Twirla

Twirla is now available from all commercial pharmacies, so you should be able to send a prescription to any local or mail-order pharmacy. Patients can also get their Twirla delivered after a telehealth visit from Pandia Health, skipping the in-person visit altogether.

Many commercial insurance plans nationwide now cover Twirla with no out-of-pocket cost. For those who do not have coverage, the Twirla savings program is available—call (866) 747-7108 or visit the manufacturer’s website for more information. Without insurance or for patients on a plan that doesn’t cover birth control, Twirla can cost an average of $175 out of pocket per box.

Bottom line

Twirla is a lower dose birth control patch option for people with a BMI <30.

Robin Watkins is the Director of Clinical Affairs and Medical Education at the Society of Family Planning. Robin is a midwife and women’s health nurse practitioner focused on expanding provider capacity to offer just, equitable, resonant, and high-quality sexual and reproductive health care. Robin provides clinical care in the Washington, DC area. When she is not talking sex or placing IUDs, you can find her riding her bike on the streets of DC or eating ice cream for dinner.
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