My patient, who is 11 years old and is developmentally delayed, fears needles and devices. What contraceptive would you recommend? #501/15

Q:        I am a clinician and my patient today asked a question regarding her 11 year-old developmentally delayed daughter.  She has decision making skills at a 4 or 5 year level and is very interested in boys.  The mother wants to place her on birth control once she hits menarche.  We duscussed Depo (DEATHLY afraid of needles), Implanon and Mirena IUD.  Implanon is near the top of my list.  Do you have any other suggestions or comments?

Janet Roscoe

Women’s Health NP

A:       

Fascinating!  Implanon (or now Nexplanon) would also be at the top of my list and if you have been inserting many of them, you know that insertion is not painful to speak of.  Now we are finding that Implanon/Nexplanon remains effective for a full 4 years and it may be effective for longer than that.  NO CONTRACEPTIVE IS AS EFFECTIVE IN PREVENTING PREGNANCY AS THE IMPLANT.  It would be safe to insert the implant before her first period.Does this approach make sense to you?  What about her mother to her?

Good luck and please do keep me posted as to what you and the family decide to do.

Email received on 8-5:  Dr. Hatcher, It’s been quite some time since I wrote you about this patient, but she appeared on my schedule today.  I would love to get your input.

Patient was, as you may recall, an 11 year-old developmentally delayed girl (functioning at 5-6 years old) who went through menarche last month.  She is interested in boys and is starting junior high next week.  Her mother is a patient of mine and we have discussed options for birth control.

Her mother:

#1. does not want Depo as patient is VERY/DEATHLY afraid of needles.

#2.  not interested in Nexplanon due to insertion (but I wonder about doing it under anesthesia).  Mother would like to go the “least invasive option).

#3,  mother wants oral contraceptive pills since patient takes a number of meds every night.

Patient’s medical history: nocturnal epilepsy – medicated with Tripletail and Zonegran.

I am concerned about dosing her correctly with OCPs (she is only 11 years old and weights 80 pounds).  They are also looking for CYCLE REGULARITY, since her menses is proving to be a big disruption to her life/day.  The nurse at school needs to monitor.

I was thinking either a middle dose of oral contraceptives (but not low due to anti-seizure meds) or possibly a progestin-only pill.  Am I forgetting any other good options or do you have any other comments?

Thanks so much for your input.

Janet Roscoe

Women’s Health NP

If you decide to try pills, I have a suggestion.  Decrease the hormone-free interval to 4 days and be sure she always has a number of months of pills ready to use. 

These two steps could increase the contraceptive effectiveness of her oral contraceptives.

Email received 5-6:  Thanks for your previous input on this patient.  As she ages, the questions and challenges continue, so I’d love to consult you again.

To recap – My patient is now a 12 year-old girl, developmentally delayed – looking for #1 cycle control and #2 contraception (more of a hypothetical risk, as she is not sexually active and mother does not anticipate this will be an issue).  Mother wants least invasive option – no needles or devices.  We decided on progesterone-only pills.  Great results – no bleeding, doing well…but significant hair thinning.  All other medications discontinued at this point.  I suggested she stay on POPs and try biotin.  Not sure if Nexplanon (different route) might improve this, but they are hesitant for any procedures.

Any other thoughts on hair loss with POPs?

Would change to COCs (low-dose) help any?

Biotin and argan oil have been recommended.

Thanks Dr. Hatcher and have a nice day.

Janet Roscoe

Women’s Health NP

5-28-2015: If the mother is not concerned about pregnancy, why is she taking progestin-only pills? 

I would consider stopping these pills since progestin-only pills would be made less effective by make less effective by the same meds that would make combined pills less effective.

Please send me a list of all the medications this girl is on at present.

Robert A. Hatcher MD, MPH

Emeritus Professor of Gynecology and Obstetrics

Emory University School of Medicine

Atlanta, GA

To learn more about the advantages and disadvantages of the Implanon implant and Nexplanon implant, oral contraceptive pills, progestin-only pills, go to: www.managingcontraception.com.   You can order all of these books listed below from our website or by calling 404-875-5001. 

Key Words:   developmentally delayed, decision skills, birth control, menarche, Depo-Provera, deadly fear, needles, Implanon implant, Mirena IUD, insertion, effective, pregnancy, period, Nexplanon implant, anesthesia, least invasive, oral contraceptive pills, noctural epilepsy, Trileptal, Zonegran, cycle, disruption, anti-seizure meds, progestin-only pills, challenges, hypothetical risk, sexually active, bleeding, hair thinning, biotin

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