When Parents Do Not Want Their Daughters on Birth Control Pills: Tips for Navigating a Difficult Clinical Situation
Lisa K. Perriera, MD, MPH, Marjorie Greenfield, MD
J of Society of Ped and Adolescent Gynecology, November 2011
“The Pill” just celebrated its 50th birthday. When looking back at this monumental discovery, how many clinicians have wished its creators had named it something other than “the birth control pill”? Imagine if it had been called “the menstrual cycle regulation pill,” “the menstrual cramp avoidance pill,” or “the anti-acne pill.” If the name had been separated from its contraceptive effects, our job of helping adolescents with menstrual maladies would be much easier. We could tell patients and their parents that this medication will safely cure dysmenorrhea, improve acne, and regulate cycles, and incidentally, prevent ovulation.
Menstrual problems, including dysmenorrhea and anovulatory bleeding, affect a significant percentage of teens. Klein et al found that in a representative sample of 2699 menarchal adolescents, 14% missed school because of severe cramping.1 Many young girls also experience anovulatory bleeding, which can be heavy or irregular enough to interfere with activities of daily living. After a bleeding disorder has been excluded in girls with menorrhagia, the best treatment option for young women with menstrual disorders is often combined hormonal contraception (CHC). Some girls explicitly request pills for the treatment of their menstrual disorders because they desire the contraceptive benefits as well as the medical benefits.
Bleeding disorder work-up
History:
o Family history of an inherited bleeding disorder
o Bleeding lasting > 15 minutes from small wounds
o Gingival bleeding
o Easy bruising
o Heavy or recurrent bleeding after surgery
o Soaking more than one pad or tampon per hour
o Spontaneous nosebleeds
o Heavy periods that cause anemia or require transfusion
Work-up:
o CBC with platelet count
o PT/PTT
o Fibrinogen or thromboplastin time
o Von Willebrand Antigen and Ristocetin cofactor
o Platelet Function Analysis
o If test results normal and history suspicious for bleeding disorder, refer to hematologist
So how can we most effectively respond when parents tell us, “I don’t want my daughter on a birth control pill,” “She is too young,” or “It will give her permission to have sex”? The best response is to listen as parents express their concerns, address the misperceptions about CHC, outline the safety and efficacy of the medications, and provide accurate information about teen sexuality, including the unique needs of their daughter.
Here are some of the concerns, misperceptions, or myths we hear parents express and how we try to respond:
Myth #1: My daughter is too young to be on birth control pills—it’s not safe for someone her age.
Parents should be reassured that once their daughter has begun menstruating, her hormone levels are similar to those of an adult woman and she is reproductively “old enough” to use CHC in the same doses as adults. There is no evidence that the pill poses any more risk to an adolescent than to an adult. Side effects such as nausea, breast tenderness, bloating, breakthrough bleeding, and minimal weight gain are not uncommon, but more serious side effects such as elevation in blood pressure, myocardial infarction, and thromboembolic events are rare. Clinicians should explicitly discuss the media’s portrayal of contraceptives as risky and place this risk into the appropriate context. It is important to explain that although the risk of venous thromboembolic events is increased, the absolute risk of this complication is extraordinarily low, particularly in a healthy, nonsmoking adolescent, and pregnancy carries more risk of venous thromboembolic events than does CHC use.
Risk of Venous thromboembolism:
o General population: 0.8/10,000
o CHC users: 3-4/10,000
o Pregnant women: 6-12/10,000
As you address risks, you have a prime opportunity to discuss the many noncontraceptive benefits of hormonal contraceptive use. All methods of combined hormonal contraception (pills, patch, and vaginal ring) have been shown to effectively regulate menstrual bleeding.5 Teens will be excited to hear that menstrual periods on the pill tend to be extremely regular—to the point where a girl can expect that her period will arrive every 4 weeks around the same day and time. There is also a 40%-50% reduction in menstrual flow with combined oral contraceptives and dysmenorrhea is reduced in 70%-80% of women. A Cochrane review found that combined oral contraceptives reduced inflammatory and noninflammatory facial acne when compared with placebo. Since adolescents are often preoccupied with their appearance, the reduction of hirsutism and acne may be particularly compelling.
Myth #2: Birth control pills cause cancer.
The Non-contraceptive Benefits of CHC
o Regulation of the menstrual cycle
o Decreased amount of menstrual flow
o Reduction of dysmenorrhea
o Improvement of acne
o Improvement of excess hair growth
o Reduction in risk of several reproductive cancers
o Suppression of ovarian cyst formation
Many families believe combined hormonal contraceptives cause cancer. Clinicians should be proactive in addressing this concern, by citing the cohort study performed by the Royal College of General Practitioners, which found the risk of colorectal, uterine, and ovarian cancer was significantly lower in pill users when compared to nonusers. Although evidence on CHC and breast cancer is mixed, providers should acknowledge that some large studies have demonstrated a slight increased risk of breast cancer in current and recent users of oral contraceptive pills.
Most data, however, indicate that this effect is minimal and disappears within 10 years of discontinuing the medication, and therefore this should not be a cause for concern in adolescent patients. Even in women with a family history of breast cancer, oral contraceptive use does not appear to significantly increase risk. Prolonged use of hormonal contraceptives has been associated with a small increased risk for cervical cancer as well.
Again, this risk should be placed in the proper context, and it may be related to confounding factors such as unprotected intercourse and multiple partners. The association between hormonal contraception and cervical cancer should be used to stimulate a conversation about effective means of risk reduction for cervical cancer, such as delaying the onset of sexual activity, limiting the number of sexual partners, and completing the human papillomavirus vaccine series.
Myth #3: Girls are more likely to become sexually active if they are on birth control pills.
One response to this concern is to ask parents if they require their child to wear a seatbelt when she is in the car. Most parents will state that they do. Then ask the parent, “Do you think wearing a seatbelt gives permission to drive in an unsafe fashion?” This type of questioning may help parents realize that contraception and sexual practices are not necessarily linked. When engaged in a discussion of sexual decision making, most parents will acknowledge that there is a great deal more that goes into a girl’s decision to become sexually active than whether or not she is on contraception. Parents should be encouraged to communicate their beliefs to their daughters, and to emphasize their values around sexual choices, regardless of CHC use. Parents should be reassured that there is no evidence that girls on contraceptives for medical indications are more likely to have sex than girls who are not.
Often parents will perceive they are “on the same team” with the clinician when they hear the clinician outline the benefits of abstinence or delaying the onset of sexual activity. An adolescent, alternatively, may respond well to hearing her provider acknowledge that the decision to become sexually active is ultimately hers alone, and that the clinician’s job is to help keep her safe and healthy no matter what she chooses. Parents may be further educated that some teens will have sexual encounters that are beyond their control, or that many teens will delay seeking hormonal contraception for some time after coitarche.
Some teens do not plan sex ahead of time but perceive it as something that “just happens.” A sexually active teen who does not use contraception has a 90% chance of becoming pregnant in one year.17 If an adolescent using a contraceptive method to treat a medical condition just happens to have intercourse, at least she will be protected from pregnancy. Parents should be applauded for educating their children about contraception, addressing teen sexuality, and initiating a method, particularly if coitarche has occurred or is imminent.
Although provision of contraceptives to teens without parental consent is legal in some states, it is often not a practical route to take, especially in a private practice setting where insurance explanations of benefits and the cost of contraceptives can compromise privacy and be a barrier to their use. A more effective approach may be to focus on the negotiation with the parents, and to convey your genuine desire to provide the safest and most effective options to treat the teen’s symptoms. Over time, parents will often come around to recognize the value of CHC for their daughter, for the alleviation of menstrual problems and/or for their contraceptive “side effects.”
