skin irritation around the area where the patch is placed and a change in the woman's sexual desires. Additional side effect information is provided in the Ortho Evra label information and the Evra Summary of Product Characteristics (SPC) and PIL. Interactions and contraindications Contraceptive effectiveness of the patch or any other hormonal contraceptive may be reduced significantly if administered alongside various antibiotics, antifungals, anticonvulsants, or other drugs that increase metabolism of contraceptive steroids. However, despite the interactions with many other antibiotics, a clinical pharmacokinetic drug interaction study showed that oral administration of tetracycline HCl 500 mg for three days prior to and seven days during use of Ortho Evra "did not reduce effectiveness of Ortho Evra." This is a significant factor in the common decision to administer tetracycline-derived antibiotics following an abortion (preventatively to fight potential infection) when synthetic hormone contraceptives are to be used afterwards. Drugs containing St. John's wort are also known to affect the effectiveness of hormonal contraceptives. It has also been found that the patch is less effective in women who weigh more than 198 pounds (90 kg). The contraceptive patch and other combination hormonal contraceptives are contraindicated in women older than 35 years who smoke cigarettes. The contraceptive patch is contraindicated for use in women with a BMI ≥ 30kg/m2. Thromboembolism All combined hormonal birth control products have a very small increased risk of serious or fatal thromboembolic events. There is ongoing research into the thromboembolic risks of Ortho Evra as compared to combined oral contraceptive pills. A recent study found that users of the contraceptive patch may have a twofold increased risk for non-fatal venous thromboembolic events compared with women who took a norgestimate-containing oral contraceptive with 35 µg of estrogen. However, a different study concluded that the risk of nonfatal venous thromboembolism for the contraceptive patch is similar to the risk for oral contraceptives containing 35 µg of ethinylestradiol and norgestimate. The contradiction in findings between the two studies is not easily resolved, because the confidence intervals for the studies are overlapping. In studies with oral contraceptives, the risk for cardiovascular disease (such as thromboembolism) is significantly increased in women over the age of 35 years who also smoke tobacco. Hence, Ortho Evra's package insert states: "Women who use hormonal contraceptives, including Ortho Evra, should be strongly advised not to smoke." According to the manufacturer, the patches introduce a 60% higher level of