Is there any reason my 13 year-old daughter should not start low-dose pills since she suffers from dysmenorrhea? #217/11

My healthy 13 year-old daughter has dysmenorrhea for 5 days each month with only mild relief with NSAIDS.  She is not sexually active.  Can you think of any reason not to start her on combined oral contraceptives?  I am thinking about Lo Loestrin.  Of course, I will take her to her pediatrician for the prescription.


Thank you!

Worried CNM Mom


Good to hear from you!

It is definitely perfectly appropriate for you to start a low-dose combined pill for your daughter.  I will send you a long somewhat related question as it includes responses from a number of others on the question you raise.  I certainly hope pills do the trick for you daughter.

 

Mirena is also a possibility.

 

Below is a copy of the case of a 12 year-old girl whom we had experts from across the country weigh in on:

 

Question #1120/9                                                                              November 18, 2009

 

Category:       Contraception: Prior to a 12 year old’s first period

 

Trigger Question:     Should the Ortho Evra patch be provided to a 12 year-old who is premenarchal?  Could this initiate her cycle?

 

Q:        I have a patient who is 12 years old, who is premenarchal, sexually active but only having oral sex at this time.  She is asking for the Ortho Evra patch in order to be protected against pregnancy.  My questions are: (1) Do you recommend this? (2) If you do recommend this, will this initiate her cycles? (3) What are going to be the effects on her system by initiating this before she has her first period, possibly initiating her menstrual cycle before she otherwise would have had them?  We have no data on patches used this way, but this has been done with combined oral contraceptive pills many times.

 

Also, FYI, I did not ask her about other forms of contraception. She was in with a friend (another 12 year old) who also has not had a menstrual cycle and who uses the Ortho Evra patch.  The patient was given condoms, vaginal contraceptive film, contraceptive and sexually transmitted disease information and she was asked to return in one month.

 

Nurse Practitioner, Medford, OR

 

A:        Clearly it would be most unfortunate for this 12 year-old person to become pregnant because oral sex leads to traditional penis-in-vagina sex AND she is not using a contraceptive. Two other tragic consequences would be for her to become infected with HIV or with another infection that could cause her to become infertile later on.

 

Each of these 3 consequences could adversely affect the rest of her life.  One of these consequences, pregnancy, definitely will not happen if she continues to have oral sex and avoids penis-in-vagina intercourse in the foreseeable future.  The other two consequences, HIV infections and infertility due to other infections are both much less likely while having oral sex (in comparison to her risk were she to start having traditional penis-in-vagina intercourse).

 

Should she decide to have traditional penis-in-vaginal intercourse, you have already provided her the best contraceptives.  Condoms along with a vaginal spermicide is what I would like to see this young girl use should she decide to have traditional intercourse.  The problem is that these are not the methods she wants to use nor do we have any indication that she will use them.  She wants to use the patch before she has had her first menstrual period.  We have no data on the wisdom of this practice.  But we do know very well that intercourse prior to a teenager’s first period can lead to pregnancy.  If she does not concur with your recommendation that she use condoms and a vaginal spermicide, I would consider it appropriate to provide her Ortho Evra patches until her first period.

Clinicians generally are concerned about providing pills or a patch for a girl who has never had a period because we simply do not have data demonstrating the safety of this practice.  We don’t know if this could have an effect on the hypothalamic – pituitary axis.  Some clinicians would while others would not provide patches or pills to your patient.  Again, the reason for the CONCERN about providing pills, patches or rings to a woman who has not yet had a period is a concern that these hormones MIGHT have an adverse effect on her hormone regulating center.  Since the strength of the hormones in the patch exceeds that of pills or the ring (the ring has the lowest estrogenic effect), pills or rings might be preferable to use over the Ortho Evra patch.

Girls and boys younger than your patient are having oral sex.  In fact, this is happening in bathrooms, closets, and stairways of schools with 10 and 11 year olds.  I have great problems with this but this behavior will continue in spite of my concerns.  You know this and so do I.  It amazes and concerns me.

My personal belief is that our sexuality is a beautiful gift of God as is our ability to reason.  It’s up to each of us to use our reason to decide when, with whom, how often, and in what way to use our sexuality.  The truth is that each individual must make these decisions for himself or herself.  Make wise decisions in the light of what you feed is the right thing for you to do.

 

My question to several colleagues was: If she sees you, will you prescribe the patch or pills for her?

 

From Dr. Jeffrey Peipert; Washington University, St. Louis: “Yes, with condoms for STD prevention.  This 12 year-old is at high risk for unintended pregnancy, STDs and other risks.  A careful social history (sexual abuse, intimate partner violence) is in order.  NOTE FROM MISSOURI: A 12 year-old cannot consent by law to vaginal sexual intercourse and must be reported (ugghh).”

 

From Dr. Carolyn Westoff; Columbia University, NYC: “Contraceptive protection is medically fine.  I’m always concerned about social protection.  I would want to know about the quality of this relationship and whether anyone (including that boy) actually cares about this girl.”

 

From Dr. Cammie Chrisman; University of Michigan: “Yes, if she wants it and is asking for it.  If she’s into it, I’m into it.  I have to say, as a provider for older women, I do have some concerns about the risks.  If a person is a low risk for venous thromboembolic events (VTE) I would prescribe it with no hesitation.”

 

From Dr. Willie Parker; Washington Hospital Center (DC): “YES, I would prescribe for her.  I am not worried about stunting growth.  Thelarche indicates estrogen presence and follicular development.  The impending menarche and her current decision makes it likely that she will be one of those pregnancies I have heard of where a young lady has a conception due to coital exposure in the first ovulatory cycle (before menses).  Just 2 weeks ago I had to coordinate abortion services for an 11 year-old who was 15 ½ weeks pregnant.  Her chief concern: ‘I missed the first day of school.’  She was turning 12 the next Sunday.”

 

From Dr. Norma Jo Waxman; San Francisco: “YES, absolutely!  We know girls get pregnant before ever having a period (really bad luck!).  But first we do an HCG pregnancy test because she may already be having sex.”

 

From Victoria Fort on 10-5: “In the case of the 12 year-old girl, you made a strong case for financial independence and repro health.  A 12 year-old is far from financially independent.  Should this bar her from receiving services (obviously you don’t think so) but how do you make it clear to her the extreme costs of being sexually active when she has yet to witness her friends becoming pregnant or contracting numerous STDs?”

 

RAH’s reply: Tough questions!!!  I am not sure it is ever possible to explain all the social and economic costs of sexual intimacy and particularly of sexual intercourse to a 12 year-old girl. 

 

She certainly is not financially independent.  And I would like for her to get good services in spite of her lack of financial independence.  But the real costs to her go so much further, as you are well aware.  One could easily write a list of 10 to 20 financial consequences for a young girl of very early sexual intercourse.  Then another list could be developed – a list of at least 20 “social costs” of sexual intimacy at a very young age.

 

Since a 12 year-old cannot, as you suggest, even begin to understand all the costs of sexual intercourse, she really can’t make an informed decision to have intercourse.  This would be an excellent argument for her NOT to start have sexual intercourse.  Parents are saying exactly this to young teenagers and preteens every day.  But still there are 12 year-old girls coming to clinics wanting contraception.

 

I would say, provide them contraception even though you are not happy with the idea of them becoming sexually active.  In other words, provide them contraception know that in many instances they are going to have intercourse no matter what I or their parents might say.

 

 

To learn more about the advantages and disadvantages of birth control pills, go to our website: www.managingcontraception.com and click on Choices.  You can also order this wonderful new educational book from our website or by calling 404-875-5001.  Do you have your copy yet?       


Key Words: 
dysmenorrhea, relief, NSAIDS, sexually active, birth control pills, Lo Loestrin, pediatrician, prescription, appropriate, low-dose combined pills, Mirena IUD

Skills

Posted on

March 7, 2011