Friday, June 15th 2012

What the CDC and WHO Know about Young Girls and Hormonal Contraceptives

Birth control pills via nateOne on Flickr Creative Commons.

Birth control pills via nateOne on Flickr Creative Commons.

I am slowly working on a book chapter on adolescent hormonal contraception, based on this blog post and conference presentation. I wanted to share some findings for your perusal. I’ve intentionally left out much analysis in favor of keeping things open-ended.

I’ve been curious about whether there are general guidelines out there for medical doctors in prescribing hormonal contraception to girls. Do they discuss the consequences of adult concentrations of hormones on girls’ immature hypothalamic-pituitary-ovarian axis? To the fact that hormonal contraception is almost exclusively tested on adult women in their twenties, thirties and forties? Do they discuss discontinuation rates, side effects?

In my first sweep of the literature, not really.

Today I’ll share with you a document by the CDC entitled U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 (this appears to be the most recent version). This is based on the WHO Medical Eligibility Criteria for Contraceptive Use, 4th edition. You can access a copy of this yourself here.

According to its summary statement, the purpose of this document is to “assist health-care providers when they counsel women, men, and couples about contraceptive method choice” (p. 3). They also emphasize later in the document that it is not intended to inform on off-label use, just contraceptive use, of contraceptives. And I do appreciate the existence of this document at all, and the hard work that must have gone into it, from the research that went into the literature, the literature that was reviewed, the experts that made determinations about what constitutes acceptable risk, and the work of putting the whole thing together. I’m glad this exists.

The way this document is organized is that each appendix looks at one type of hormonal contraceptive, and the possible contraindications for taking it if you have a particular characteristic or medical condition. So “age” is a category for some appendices, and sometimes within a characteristic like smoking or condition like migraines, age is a sub-category.

So first, I also want to give the experts on this panel a giant shout-out for the following two statements, in the category “vaginal bleeding patterns:”

On vaginal bleeding patterns: “Irregular menstrual bleeding patterns are common among healthy women.”

On adolescent menstrual cycles: “Menstrual irregularities are common in postmenarche and perimenopause and might complicate the use of [fertility awareness-based] methods.”

Yes, this! This is something many doctors do know, yet somehow it doesn’t always get conveyed to patients… or when it is conveyed to patients, the patients are unsatisfied with the explanation and want a prescription to become “regular.” I would love for all of us to think on what it would take to produce better doctor-patient communication in a way that gets fewer women on hormonal contraception if the only reason they are on it is because they think they need a “regulator.”

Adolescents: We Are More than Our Bone Mineral Density

I read through the “age” sections in each appendix to see what contraindications were expressed, and I put it together in a handy little table for you. Here are the recommendation categories used so that you understand what the table means.

  1. A condition for which there is no restriction for the use of the contraceptive method.
  2. A condition for which the advantages of using the method generally outweigh the theoretical or proven risks.
  3. A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.
  4. A condition that represents an unacceptable health risk if the contraceptive method is used.

I also searched the document for the following words: girls, juvenile, adolescent, and young. Girls turned up a handful of hits, but only in the references, juvenile did not appear at all, adolescent appeared three times in the document, and young only twice. I’ll share the three adolescent and two young findings.

Page 11: Bone mineral density is lower in adolescent girls using combined hormonal contraceptives, but bone mineral density may not predict postmenopausal fracture risk.

Page 34: Bone mineral density and fracture risk is unknown in adolescents using depo medroxyprogesterone acetate, or Depo Provera.

Page 37: Obese adolescents are more likely to gain weight than nonobese adolescents on depo medroxyprogesterone acetate.

Page 54: I will share this quote on the use of intra-uterine devices, because I think the wording is interesting, as well as the lack of a citation: “Concern exists about both the risk for expulsion from nulliparity and for STIs from sexual behavior in younger age groups.”

Page 77: Younger women are more likely to regret sterilization than older women.

So there you have it. Two discussions of bone mineral density, one on weight gain, one uncited concern about IUD expulsion or STIs, and mention of a study that younger women may regret sterilization.

What do you make of this? What other concerns might an adolescent have who is considering hormonal contraception? What research should be done to better understand this age group? And finally, what would it take to produce recommendations that take into account non-contraceptive uses of hormonal contraception (this seems especially important to me to produce more inclusive criteria that looks at off-label use, but also people with different sexual identities)?

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