A pediatrician recommends that a teenage girl begin using oral contraceptives, but her parents disagree with use of them. They are seeking a second opinion.
A pediatrician refers to you a 14-year-old patient, AW, with severe dysmenorrhea and a heavy menstrual flow. Her periods occur every 28 to 35 days and have been painful since age 13 years, about 1 year after menarche. Cramps start with her period, are often accompanied by vomiting and diarrhea, and are worst during the first 2 days of her menses. During this time, she saturates a sanitary napkin every 2 to 3 hours. She occasionally takes ibuprofen for the cramps, but it does not relieve them. She cannot get out of bed and misses 1 or 2 days of school most months.
In private conversation, AW denies sexual activity. On examination, her pulse is 95 bpm, her blood pressure is 94/60 mm Hg, and her respiratiory rate is 18 breaths per minute. She appears to be a healthy 14-year-old girl. Physical exam findings are otherwise normal. A urine pregnancy test is negative. Her hemoglobin is 9.2 mg/dL. A pelvic ultrasound obtained by the referring pediatrician shows normal ovaries and uterus. AW's mother tells you that the pediatrician wanted to start AW on oral contraceptives, but she and her husband do not believe in giving oral contraceptives to a teenager and so they declined. They are coming to you for a second opinion.
We all have seen this clinical scenario: the adolescent with a menstrual problem who would benefit from taking oral contraceptives but whose parents object. The most commonly prescribed and effective treatment for most menstrual disorders is a combined hormonal contraceptive.
Helping teens with menstrual disorders would be much easier if this medication were called the "cycle regulator pill," "period cramp reducer pill," or the "acne prevention pill," rather than the "birth control pill" because too often, although it is the best treatment option for menstrual disorders and acne, parents do not want their daughters to have it simply because it is a form of birth control.
This article will discuss how to nego-tiate effectively with parents who are resistant to their daughters taking combined hormonal contraceptives and review alternative treatment options.
Combined hormonal contraceptives for dysmenorrhea
Combined hormonal contraceptives constitute first-line management of severe dysmenorrhea in patients who desire contraception. In women who are not sexually active, combined hormonal contraceptives provide optimal therapy for dysmenorrhea that is unresponsive to appropriately dosed nonsteroidal anti-inflammatory drugs (NSAIDs). Approximately 14% of menstruating teens miss school because of menstrual cramping, making menstrual problems a leading cause of school absence.1
Oral contraceptive pills reduce dysmenorrhea in 70% to 80% of women who use them.2 Moreover, combined hormonal contraceptives, dosed continuously, provide the option of avoiding menstruation altogether for girls and women who prefer that regimen and for those who continue to have pain on cyclic hormonal treatment.
In addition, all forms of combined hormonal contraceptives (ie, pills, patch, and vaginal ring) effectively regulate menstrual bleeding. Research shows that combined oral contraceptives (COCs) reduce menstrual bleeding by 40% to 50%.3-5 Amesse et al found that in adolescents with von Willebrand disease, COCs reduced menstrual bleeding in 86% of patients.6 A Cochrane review found that COCs reduced inflammatory and noninflammatory facial acne compared with placebo.7 In addition, research shows that COCs reduce the risk for certain types of cancers. The Royal College of General Practitioners found that the incidence of colorectal, uterine, and ovarian cancer was significantly lower in pill users compared with nonusers, and that use of combined hormonal contraceptives is not associated with an increased risk for any type of cancer.8
It seems so easy. We prescribe a daily pill that is unlikely to cause adverse effects, may dramatically improve cramping, bleeding, acne, increased hair growth, and irregular menstrual cycles, may reduce the risk for uterine or ovarian cancer, and has the added benefit of preventing pregnancy. But some parents are resistant to giving a teenager a contraceptive. They may say, "I don't want my daughter on a birth control pill; she is too young," or "It will make her think she has permission to have sex," or "What will other parents think if they find out my daughter is on a birth control pill?"
Parents also may be concerned about the risks associated with hormonal contraceptives.